
Class. 
Book_ 



— 



Copyright N?_ 






CQEXRIGHT DEFOSIC 



SURGICAL AND OBSTETRICAL 
OPERATIONS 



W. L. WILLIAMS 

Professor of Obstetrics and Research Professor of the 

Diseases of Breeding Cattle (Formerly Professor of 

Surgery and Obstetrics) in the New York State 

Veterinary College at Cornell University. 

"With the collaboration of 

JAMES N. FROST 

Professor of Surgery 

in the New York State Veterinary College 

at Cornell University 



Embodying portions of the OPERATIONSCURSUS of Dr. Pfeiffer, 

Professor of Veterinary Science in the 

University of Giessen 



FOURTH REVISED EDITION 



PUBLISHED BY THE AUTHOR 
ITHACA, NEW YORK 

1919 



spin 

mi 



Copyright, 1919 

by 

W. L. WILLIAMS 



OtC -8 !9|9 



Press oj — — ^— — 

ANDRUS & CHURCH ITHACA N. Y. 



©CU535965 



PREFACE TO THE FOURTH EDITION 

The reception accorded by the veterinary profession, to 
the three prior editions of this little volume encourages the 
author to prepare and publish a fourth edition under the 
belief that it fills a certain need in veterinary literature. 
As in prior editions, so in this, much of the material and 
illustrations from Dr. PfeifTer's Operations-Cursus are 
retained, that fact alone indicating the high esteem enter- 
tained by the author for his distinguished colleague. 

The volume is primarily designed for the use of stu- 
dents in laboratory surgery and embryotomy in which 
the student performs the surgical operations described, 
on animals procured for the express purpose, under 
chloroform anaesthesia whenever possible, after which 
the subject is destroyed while still anaesthetized. At 
the same time it has been aimed to render the volume of 
the greatest possible value to the practitioner consistent 
with this plan. The operations included under this scheme 
are necessarily limited to those which can be reasonably 
well performed on comparatively sound animals of little 
value and regularly procurable for laboratory purposes. 
In the present edition the author has enlisted the hearty 
collaboration of his former student, associate, and finally 
successor, Dr. James N. Frost, Professor of Surgery. His 
long experience as a teacher of surgery, his unquestioned 
skill, and his enthusiastic devotion to progressive ideals in 
his work add greatly to the value of the volume. The list 
covers a wide range and is designed to give to the student 
as thorough training as is practicable in a laboratory course 
and includes well nigh all the more important varieties of 
confinement, anaesthesia, disinfection, sutures, bandaging, 
dressing and other adjuncts to operative work. The 
chapter on trephining of the facial sinuses has been dealt 
with at length in order to fully and clearly describe the 
author's method of operating. 



iv PREFACE TO THE FOURTH EDITION 

The operation for the surgical relief of roaring in horses, 
introduced and developed by the author with the collab- 
oration of Dr. Frost in 1905, and soon adopted as the 
standard throughout the world, has continued to engage 
our attention and every effort has been made to keep the 
technic thoroughly up to date.. 

Generally but one method of operating is described, the 
one chosen being that which in the author's experience has 
proven the most valuable in actual practice. No operation 
has been introduced purely for practice but each one has 
been tested and known to have practical value. 

When two methods of operating are given, they are in- 
serted because each has definite points of superiority over 
the other. One method may be specially applicable in a 
given case, another in a different patient where the same 
operation is to be performed. For example, a milk cow is 
best spayed through the vagina while a heifer must be 
operated upon by an incision through the abdominal walls. 

Considerable stress has been laid upon the surgical 
anatomy of the parts involved in each operation ; some uses 
of the various operations are mentioned ; some of the chief 
dangers of each are pointed out and in some cases refer- 
ences to literature upon the operation of the diseases for 
which the operation is designed, are cited. 

Figures 14, 15, 17, 23, 29, 35, 39, 40, 49, 50, 
53> 54» 55. 57> 60, 61, 64-6S are from Dr. Pfeiffer's 
Operations-Cursus ; and the remaining plates and figuers 
were either drawn under the direction of the author or 
were made from original photographs. 

W. L. Williams. 

Corjiell University, Sept., ipip. 



CONTENTS 
A. SURGICAL OPERATIONS 

I. OPERATIONS ON THE HEAD : 

Extraction of Teeth 2 

Repulsion of Superior Molars 7 

Repulsion of Inferior Molars 9 

Trephining the Facial Sinuses 14 

Trephining of the Frontal Sinuses 17 

Trephining the Superior Maxillary Sinuses 24 

Trephining the Inferior Maxillary Sinuses 29 

Trephining the Nasal Fossae 3 1 

Poll Evil Operation 35 

Dehorning of Cattle = 39 

Ligation of the Parotid Duct 44 

Entropium Operation 47 

Trifacial Neurectomy 48 

II. OPERATIONS CN THE NECK : 

Opening the Guttural Pouches 52 

The Roaring Operation 55 

Tracheotomy 63 

Intra-tracheal Irrigation 65 

Intravenous Injection 66 

Phlebotomy 68 

Ligation of the Carotid Artery 70 

Esophagotomy 72 

III. OPERATIONS ON THE TRUNK AND THE GENITAL ORGANS : 

Puncture of the Chest 75 

Puncture of the Intestine 76 

Rumenotomy 7S 

Resection of the Intestines S4 

Subcutaneous Caudal Myotomy 87 

Caudal Myectomy for Gripping of the Reins 89 

Amputation of the Tail 91 

Urethrotomy 93 

Amputation of the Penis 96 

Vaginal Ovariotomy in the Mare ior 



CONTENTS 



Vaginal Ovariotomy in the Cow 109 

Ovariotomy in the Cow by the Flank 112 

Ovariotomy in the Bitch by the Flank 113 

Ovariotomy in the Bitch by the Linea Alba 118 

Ovariotomy in the Cat 120 

Castration of Cryptorchid Horses 121 

Castration of Cryptorchid Boars 127 

IV. OPERATIONS ON THE EXTREMITIES : 

Tenotomy of the Flexor Tendons of the Foot 129 

Tenotomy of the Peroneal Tendon (Stringhalt Operation) 132 

Tenotomy of the Cunean Tendon (Spavin Operation) 133 

Neurectomy 137 

Digital Neurectomy 139 

Plantar Neurectomy 142 

Median Neurectomy 145 

Ulnar Neurectomy 148 

Sciatic Neurectomy 152 

Anterior Tibial Neurectomy 156 

Resection of the Lateral Cartilages (Bayer) 159 

Modified Quittor Operation 165 

Resection of the Flexor Pedis Tendon 167 

Amputation of the Claws of Ruminants 169 

Bayer's Sutures 172 

B. 

EMBRYOTOMY OPERATIONS : 

Cephalotomy 175 

Decapitation 177 

Subcutaneous Amputation of Anterior Limb 178 

Amputation at the Humero-radial Articulation 181 

Detruncation 181 

Destruction of the Pelvic Girdle, Anterior Presentation 185 

Amputation of the Anterior Limbs at the Tarsus 188 

Intra-pelvic Amputation of the Posterior Limbs, Breech Presen- 
tation 190 

Evisceration of the Fetus 1__ 194 



INTRODUCTION 

Many details must be omitted from the succeeding text 
which are of importance in each operation, but which, if 
inserted, would render the volume unwieldy in size for the 
purpose designed. 

These details are in a measure alike in each case, and it is 
assumed that the student has already familiarized himself 
with them. The more important of these may be summa- 
rized as follows : 

i. The subject should be securely confined in each case 
as directed, because the method designated has been found 
effective in the operation under description, and serves to 
fix the relations of the parts in such a way as to conform to 
the surgical anatomy of the region as outlined in the text. 
It is to be constantly borne in mind that a change in the 
attitude of the animal may cause profound alterations in the 
relations of parts, which displacement may greatly embarass 
the operator, or even prevent his carrying out the operation 
according to the technic given. In securing an animal for 
operation the whole body should be confined in a way that 
will sufficiently control movements and will insure safety to 
the patient and operator ; the part to be operated upon must 
be so fixed as to properly limit its motion and in a position 
to afford the greatest facility for the carrying out of the 
operation according to the technic given. 

2. Anaesthesia should be carefully carried out everywhere 
possible, because in addition to the humane sentiments in- 
volved, the resulting perfect control of the animal is an 
essential in aseptic or antiseptic surgery. The student 
should make a careful study of anaesthesia in these exercises 
and acquire invaluable experience and confidence for their 
use in actual practice. 

3. Disinfection must be scrupulously applied in every de- 
tail since upon its effectiveness must rest the verdict of 
success or failure as measured by modern surgical thought . 



INTRODUCTION 



The operator's finger nails should be well trimmed, smoothed 
and cleansed, and his hands and arms thoroughly scrubbed 
with a brush in hot water and soap for a period of fifteen 
minutes, and all dirt and old epidermal scales removed. 
The parts should then be disinfected. This may be accom- 
plished by immersing the hands in a hot concentrated solu- 
tion of permanganate of potassium for ten minutes and then 
decolorizing them in a strong solution of oxalic acid in boiled 
water. 

Or the hands may be disinfected after the washing with 
soap and water by immersing and scrubbing them for ten 
minutes in a i to iooo solution of corrosive sublimate, but 
in order to make this thoroughly effective the solution needs 
be alcoholic, or the hands should first be immersed in 
alcohol, ether, or other substance capable of dissolving fats 
and permitting the disinfectant to penetrate to every part 
without being obstructed by sebum or fat. Great care 
should be exercised by the student not to touch any object 
with his hands after they have been disinfected for the 
operation, unless such object has also been disinfected or 
sterilized, or in case it becomes necessary to touch objects 
not sterile, the disinfecting process should be repeated before 
proceeding further with the operation. This constitutes 
one of the most difficult of all details for the beginner to 
acquire, and each failure should be remedied by repeating 
the process over and over until the habit of maintaining 
effectual asepsis is acquired and fixed. 

The operative field should always be carefully shaved be- 
fore beginning the operation, and the shaved area should 
always be ample, so as to insure against contamination from 
adjacent hairs, as well as to give a clear view of the field. 
The area should then be disinfected in a reliable manner, 
that advised for the operator's hands serving as a type. 
Whenever circumstances will permit, the operative field 
should be kept in an antiseptic bath or pack for twenty-four 



INTRODUCTION 



hours prior to the operation in order that the deeper parts 
of the skin, especially the hair follicles and sebaceous glands, 
shall become thoroughly disinfected, a process well nigh 
impossible in a short period. 

The suturing, dressing and bandaging of the wound 
should be carried out carefully in every case and no opera- 
tion left without completing it in the best manner possible. 

The student should make each operation as real as possible 
and not omit any detail even if he thinks he already knows 
it sufficiently well, as the repetition of a supposedly familiar 
detail serves an important purpose in the fixing of a habit 
which is inestimably more valuable to the surgeon than any 
theoretical knowledge of technic. 

The safe surgeon is he who has so accustomed himself to 
the technique of asepsis and antisepsis that he carries it out 
rigidly in an automatic manner and is thus free to concen- 
trate his entire attention on the surgical problems before 
him. One of the most, if not the most, difficult lesson to 
teach the student is asepsis, which in its final analysis is 
cleanliness. It is difficult because cleanliness is an integral 
element in character. A man is clean or he is dirty. If 
clean in general, he will be clean as an operator, but if he 
habitually goes about with dirty hands and in dirty cloth- 
ing, if his office is filthy, and his surgical equipment unclean 
and in disorder, it is virtually impossible in such a realm of 
filth to create an oasis of cleanliness during a surgical opera- 
tion. Consequently the student in learning surgery must 
learn cleanliness of habit as a rule of life so that when 
engaging in a surgical operation, he carries with him the 
habit of being clean, and surgical cleanliness is then in 
entire harmony with his daily life. 

The student who consults his interests will go yet farther 
and prior to undertaking any operation on the living subject 
will study the regional anatomy of the part on the cadaver 
and learn therefrom all that he can of the structure of the 



INTRODUCTION 



part, which knowledge he must finally complete upon the 
living animal. No dissection of the cadaver can ever teach 
true surgical structure as the dead tissues can not be like 
the living, but such dissection can and does give great aid 
and should be pursued as far as it can lead and enough will 
still remain to be learned on the living subject. It is to be 
constantly remembered that anatomy deals with the struct- 
ure of the dead body while surgical operations are performed 
upon the living structures : they are not alike. 

The student should further take occasion to study in con- 
nection with each operation the object or objects for which 
it is performed in practice, its effect on the diseased or other 
parts, the untoward results to be anticipated, etc. 

Suggestions occur from time to time in the text designed 
to aid the student in these lines and help weave connecting 
bonds between the operation, its objects and results. 

Surgical operations may in themselves be valueless or 
worse and acquire value only when properly correlated to 
disease and skillfully performed. 



Surgical and Obstetrical Operations 



A. SURGICAL OPERATIONS 



I. OPERATIONS ON THE HEAD 
DENTAL OPERATIONS 

The grinding teeth of the horse, consisting of three pre- 
molars and threemolarsin each row, are of such dimensions 
and attachments that their removal in case of disease or 
defect often presents difficulties of no small degree. 

These teeth attain their greatest size at the time of erup- 
tion and most of each tooth remains firmly imbedded in its 
alveolus while a very shallow crown projects into the buccal 
cavity. The teeth are gradually pushed out of their alveoli 
when their crowns are worn away by attrition as age ad- 
vances and the proportion of the intra- to the extra-alveolar 
part gradually decreases until in very old animals the alveoli 
become obliterated and the last vestige of what was once the 
apex of the fang rests insecurely in the buccal mucosa. 

The facility with which teeth may be extracted increases 
with the age of the animal, being as a rule easily drawn 
with forceps in old, while in case of freshly erupted teeth in 
young horses it may be almost or quite impossible to extract 
them with forceps of any kind, except in those cases where 
they have become somewhat loosened as the result of disease 
or accident. When aberrations in development occur, lead- 
ing to the formation of dental tumors or odontomes the 
possibility of extraction by means of forceps is frequently 
wholly excluded. In cases where dental disorder has led 
to empyema of the facial sinuses, even if the tooth may be 
drawn by means of forceps, further operation is generally 



EXTRACTION OF TEETH 



necessary, in order to assure recovery, by the removal of 
the effects of the disease of the tooth. 

The removal of molars may therefore involve extraction 
with forceps, trephining the dental alveolus with repulsion 
of the tooth and tre'phining of the sinuses because of em- 
pyema or other pathologic conditions referable to the dental 
affection ; consequently all of these should be studied as 
related topics. 



1. EXTRACTION OF TEETH 
Figs. 1 and 2 

Instruments. Extracting forceps, fulcra of various sizes, 
mouth speculum with abundant lateral^working room, tooth- 
pick, splinter forceps, reflecting lamp. 

Technic. In simple cases with a quiet animal the patient 
may be sufficiently confined by being backed into a corner 
or very much better by being secured in stocks. In compli- 
cated cases or very resistant animals, it is best to place the 
patient upon the operating table or in default of this, to cast 
and secure in lateral recumbence on the sound side. 

Apply the speculum and identify the diseased tooth by 
manual exploration ; determine if the tooth be of unnatural 
size or form, if it be loose, if the gums be separated from 
its neck at any point, if it be out of line with the other teeth 
in the row, if it be painful to the touch, if it be split, etc. 
An external tooth fistula or a tumefaction over the affected 
member may aid in distinguishing it. Aid may also be 
had by illuminating the mouth with a reflecting electric or 
other lamp. 

It is highly essential, both for the examination of the 
teeth and for operating upon them, that the halter be very 
loose about the cheeks. When closely fitted to the animal 



EXTRACTION OF TEETH 



while the jaws are closed, the wide opening of the mouth 
by means of the speculum causes the nose-chin band of the 
halter to become very tight and presses the cheeks against 
the labial surfaces of the grinders so forcibly as to prevent 
easy access to that surface. The halter pressure also causes 
pain and abrasions of the buccal mucosa owing to the 
forcible pressure of the cheek against the corners of the 
superior grinders. 

Remove any accumulations of partially masticated food 
by means of the toothpick or fingers. 

In applying the forceps, have an assistant draw the 
tongue out at the commissure of the lips on the sound side 
and introducing one hand into the mouth, place the index 
finger on the posterior border of the diseased tooth and 
with the other hand, push the opened "forceps backward 
upon the dental row until they reach the diseased member, 
then firmly grasp it with the instrument, pressing the 
jaws down as deeply as possible against the alveolus. 

In many cases the diseased tooth can be clearly seen, 
especially with the aid of the reflecting lamp, and the 
forceps may be readily applied by the sense of sight, which is 
frequently preferable to that of touch. 

Withdraw the free hand from the mouth, grasp the 
forceps handles firmly and loosen the tooth in its alveolus by 
establishing and maintaining as long as necessary a gentle 
to and fro lateral movement. The tooth is thus loosened 
in its alveolus by causing it to revolve very slightly back 
and forth on its long axis, thereby spreading the alveolar 
cavity. Care is to be taken not to apply too great force to 
the tooth in attempting to loosen it by rotation. If the 
force applied is excessive, the tooth fractures transversely 
at or below the gums and thereafter extraction with forceps 
becomes impossible. When the tooth has become well 
loosened, the fact is indicated by its revolving with the 
forceps and by an audible crepitant sound caused by the 



EXTRACTION OF TEETH 



passage of air bubbles to and fro through the blood and 
lymph in the alveolus. Maintain the forceps in position 
with one hand and with the other introduce the fulcrum to 
a point where the depression on its superior surface will 
receive the projecting rivet-head of the instrument or in an 
otherwise secure position affording a safe support, while 
the inferior surface rests evenly upon the crown of a tooth 
anterior to that which it is desired to extract, as is shown 
in Fig. i. The fulcrum needs to be held firmly in place in 
order to prevent it from gliding away under pressure. 

In extracting the first premolars there is no opportunity 
for resting the fulcrum on teeth anterior thereto and con- 
sequently forceps have been made with fulcra beyond the 
forceps jaws resting upon teeth more posteriorly situated. 
This is not essential. If the tooth is thoroughly loosened, 
as it should be, one hand placed in the interdental space 
with the dorsal surface against the jaw and the volar grasp- 
ing the instrument, will serve as an effective fulcrum. 

In other cases an iron or steel fulcrum is not essential, 
but a stick of hard wood of proper size and form acts quite 
as efficiently and may even keep its position better because 
the teeth upon which it rests sink into it somewhat. On 
the whole the fulcrum is not so important as some have 
considered it, since, after a tooth is loose enough to be 
drawn with its aid, a very trifling additional loosening will 
permit it to be easily lifted from its alveolus without it. 

The tooth fang is extracted by forcing the handles of the 
forceps toward the jaw in which it is located, so that as it 
is gradually drawn out the forceps tend to pivot on the 
fulcrum in a way to permit the tooth to emerge from its 
alveolus in the direction of its long axis. By referring to 
Fig. 2 it will be seen that the long axes of the different 
teeth vary, that of the molars being obliquely forwards from 
fang to crown towards the incisors, while the crowns of the 
premolars are directed obliquely backwards toward the 



EXTRACTION OF TEETH 




FIG. I. 

Extraction of .Teeth. 

Sagittal section through the oral cavity, showing plan for extract- 
ing the third inferior premolar, viewed from within the mouth. 
A Forceps jaws applied to third premolar. 
B Fulcrum resting upon first premolar. 
CC. Plates of mouth speculum resting upon incisor teeth. 



EXTRACTION OF TEETH 



molars. The slant of the teeth is most marked at the ends 
of each arcade while at the middle they acquire an almost 
perpendicular position. 

In drawing the last molar the back of the forceps will 
generally strike against the opposite dental arcade before 
the tooth has completely emerged from its alveolus and in 
order to complete its removal it may be necessary to take 
a deeper hold with the extracting forceps or withdrawing 
these, complete the operation with the hand. In young 
horses where the teeth are very long, we have found it im- 
possible to complete the extraction until the tooth has been 
divided transversely by means of the tooth cutting forceps. 
The dangers in the extraction of teeth are chiefly : 
i. The transverse fracture of the tooth, leaving the fang 
still fixed in the alveolus, a danger not infrequently un- 
avoidable when the crown has become greatly weakened by 
disease so that it lacks the necessary power of resistance ; 
under most other conditions transverse fracture may be 
largely guarded against by the careful securing of the 
patient in a manner to effectively prevent sudden throwing 
of the head while the forceps are applied, and by using good 
judgment in the amount of force exerted while loosening 
the tooth in its alveolus. As stated above, one should not 
expect to be able to extract with forceps the teeth of very 
young horses which have not become partly detached by 
disease or in which the fangs are the seat of odontomes. 

2. Fracture of the alveolar walls is an accident which 
may generally be prevented by proper care in the applica- 
tion of force and the avoidance of any attempt to extract a 
tooth when the existence of an enlargement of the fang is 
apparent or suspected. 

3. The tooth may slip from the forceps into the pharynx 
and be swallowed, an accident avoidable by proper securing 
of the patient and by inserting the hand into the mouth as 
the tooth begins to emerge from its alveolus, and if need 
be, by grasping it with the fingers. 



REPULSION OF TEETH 



2. REPULSION OF TEETH 
Fig. 2 

Uses. The removal of molars, pre-molars, tooth fangs 
from which the crowns have been broken away, alveolar 
odontomes, etc., which can not be removed safely by means 
of the forceps. 

Instruments. Mouth speculum, razor, convex scalpels, 
trephine, bone gouge, IyUer's sharp bone forceps, (rongeur 
forceps) light and heavy bone chisels, mallet, tooth punch, 
curette, compression artery forceps, scissors, needles, 
thread, absorbent cotton, antiseptic gauze, extracting 
forceps, splinter forceps, tenacula, metal probe. 

Technic. Secure the animal in the lateral recumbent 
position with the affected side up. The operating table 
affords by far the best means for securing for the conven- 
ience and safety of operator and patient. If the sinuses are 
so involved as to make possible the inhalation of pus, blood 
or other injurious matter, perform tracheotomy in ample 
time to avert danger. Anaesthetize locally or generally as 
required. Shave and disinfect the operative area and 
trephine according to the method described in the following 
chapter, down through the alveolar plate immediately over 
the fang of the affected tooth. Avoid dulling the trephine 
by striking it against the tooth fang. 

If an external fistula exists, the identity of the affected 
tooth is best determined by passing a metallic probe through 
it against the diseased fang, while one hand is passed into 
the mouth and the location of the probe more fully ascer- 
tained. Care should be exercised in trephining not to injure 
the adjoining teeth. This is best accomplished by palpating 
with one hand inside the mouth and the other outside in a 
manner to locate the fang of the affected tooth. The danger 
is further decreased by using a trephine, the diameter of 
which is considerably less than the antero-posterior diameter 
of the tooth. 



REPULSION OF TEETH 



The identification of a given tooth of ten gives much diffi- 
culty to the beginner. The identification should be made 
by passing the finger tips along the lingual or inner surface 
of the row of teeth involved and enumerating them from 
before backward. The line of demarcation between two 
contiguous teeth is to be recognized by the depression be- 
tween their necks. The student must remember that the 
first premolar has a much greater antero-posterior diameter 
than the succeeding teeth. Care needs to be taken, also, 
not to confuse the longitudinal grooves due to the plicae 
in the dentine and enamel, especially of inferior grinders, 
with the inter-dental depressions. 

After removing the disc of bone isolated by the trephine, 
control all hemorrhage and then enlarge the opening and 
remove the bony tissues till the tooth fang is bared its entire 
width. Insert a scalpel or bone chisel betwen the external 
face of the bone and the soft tissues at the oral margin of 
the trephine opening, and having one hand in the oral cavity 
with the fingers resting upon the alveolar border on the 
lateral side of the tooth to serve as a guide, push the scalpel 
or chisel along between the bone and soft tissues until it 
emerges from 'the gums alongside the affected tooth. 
Extend this separation backward and forwards until the 
soft tissues are completely detached from the alveolar wall 
over the entire area of the diseased member. 

When operating upon the superior molars, the fangs of 
which are covered by the zygomatic ridge, the chisel or 
scapel cannot be pushed directly from the trephine opening 
into the mouth between the soft tissues and the bone because 
the line is concave instead of direct. In these cases it is 
best to detach the soft parts from the zygoma only, at first 
and then remove the plate of the ridge with the bone for- 
ceps or chisel, after which the line into the mouth is direct 
and the instrument can be readily pnshed between the soft 



REPULSION OF TEETH 



and osseous tissues for the remainder of the distance and 
the separation completed. 

The operator needs to use great care in making his way 
through the zygoma down to the mouth. Just beneath the 
ridge, the larger branches of the facial nerve (7th, cranial 
nerve) run parallel to the ridge directly under the skin. If 
the operator inadvertently cuts or injures the nerve 
branches, the lips are paralyzed and drawn to the opposite 
side. The paralysis may be permanent and greatly disfigure 
the animal. The operator needs to be careful, also, in this 
part of the operation to avoid wounding the subzygomatic 
artery and vein, SZ, Figs. 8, 9, which run parallel to the 
zygoma, deeply imbedded in the masseter and lying almost 
immediately against the bone. In separating the soft tissues 
from the bone, therefore, the operator must be careful to 
keep immediately against the bony plate. 

The trephining for the repulsion of the superior molars 
involves the invasion of the facial sinuses. In a majority 
of cases, the sinuses are the seat of empyema, so there is 
the double object of removing the diseased tooth and pro- 
viding means for overcoming the empyema. This is de- 
scribed in the following pages under trephining of the 
sinuses. 

The repulsion of the inferior grinders is one of the most 

hazardous operations undertaken by veterinarians, unless 
accurate anatomical knowledge and surgical technic are 
brought to bear upon the operation. The inferior grinders 
are wedge-shaped, the fang being the apex of the wedge. 
The inner and outer alveolar plates rest directly upon the 
tooth. If the punch slips by the fang of the tooth and 
engages either internal or external plate, disaster follows. 
The masseter muscle covers the fangs of the inferior molars 
and the operator must avoid mutilating it as far as possible 
in order to prevent unsightly blemishing. The best plan 
for laying bare the alveolar wall over the fang of the tooth 



10 



REPULSION OF TEETH 



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REPULSION OF TEETH 11 

it is desired to repel, is to make a curved incision at the 
antero-inferior angle of the masseter muscle commencing 
about one inch above the border of the inferior maxilla, just 
behind and parallel to the parotid duct. Follow the duct 
until the inferior attachment of the masseter is reached, and 
then turn backward along the inferior masseter border for 
a sufficient distance. Detach the inferior maxillary attach- 
ment of the masseter as far as may be required and turn up 
the semicircular flap thus acquired, laying the surface of 
the bone bare. 

After properly locating the region of the tooth fang, the 
trephining may proceed. By this method the operator 
avoids wounding the 7th nerve to produce paralysis of the 
lower lip, and also reduces to a minimum the resulting scar, 
and has the best access to the field for trephining. 

The bone of the operative area having been properly 
bared, the trephine opening completed, and the soft tissues 
over the course of the tooth detached from the trephine 
opening into the mouth cavity, the operator should proceed 
to remove the external alveolar plate as indicated in Fig. 2. 

With a light, well sharpened, narrow bone chisel cut 
away and remove the external alveolar plate over the entire 
extent of the tooth, from the oral margin of the trephine 
opening into the mouth cavity. Hold the chisel so that 
the outer edge is inclined from the center of the affected 
tooth toward the adjoining one, thus making a bevelled 
channel through the alveolar plate tending to loosen the 
isolated section of bone by driving it outward. Drive the 
chisel for only a short distance on one side, then upon the 
other, and thus break the alveolar plate away in small sec- 
tions and avoid an extension of the fracture to neighboring 
alveoli and damage to adjacent teeth. Care should be taken 
that the bone chisel is sharp, otherwise extensive fractures 
of the bone occur. With gouge and chisel remove all rem- 
nants of bone over the lateral side of the tooth laying it 
completely bare as shown in Fig. 2. 



12 REPULSION OF TEETH 

The soft tissues of the part should not be disturbed 
beyond the excision of the circular piece covering the disk 
of bone removed by the trephine, and the detaching of them 
from the portion of bone to be chiseled away. 

When the tooth has been bared so that every part of its 
lateral surface can be seen or felt, the punch may be placed 
against the end of the fang, a few firm, quick blows given 
with the mallet, so directed that the force is in a line with 
the long axis of the tooth, and the organ driven into the 
mouth where it is seized by the forceps or the hand and 
removed. If the tooth be not readily and safely dislodged 
in this way, place the heavy bone chisel against it and with 
the aid of the mallet comminute the tooth by breaking it 
transversely and splitting it longitudinally, in which process 
the fragments are generally loosened from the alveolar walls 
and can then be readily removed with the aid of the gouge, 
or heavy dressing or splinter forceps. The repulsion of in- 
ferior grinders is generally rendered more safe by dividing 
them transversely with the chisel at one or two inches from 
the fang and prying out the detached piece. The operator 
then has a square end against which to place the punch. 
The shortening of the tooth also facilitates pushing it into 
the mouth as it does not jam against the superior grinder. 
Remove carefully all fragments of tooth or of loosened bone, 
cleanse and disinfect .the wound, pack with antiseptic gauze 
and dress daily. 

In cases where a fistulous opening remains after repulsion 
of molars without the removal of the alveolar wall, or if a 
tooth has been drawn by means of the forceps and the 
alveolus fails to heal, the bony plate should be removed in 
the above manner and the alveolar cavity thus opened freely 
for inspection and remedial measures. 

Dangers. Wounding of the adjoining tooth is to be 
avoided chiefly by carefully locating the fang of the affected 
one and placing the instrument as exactly as possible over 



REPULSION OF TEETH 13 

its centre, by using a trephine not exceeding 2 to 2.5 cm. in 
diameter and cautiously sawing through the compact layer 
of the external plate only, removing the cancellated tissue 
with the gouge and extending the opening in the desired 
direction after the outlines of the tooth fang have been 
clearly determined. If an adjoining fang is wounded, the 
tooth should be removed as it will not heal but will result 
in a permanent tooth fistula. 

Fracture of the alveolar walls of the inferior maxilla 
may occur during the removal of the external alveolar plate 
with the chisel or the repulsion of the tooth with the 
punch. The first is to be averted by care in having the 
chisel sharp, by observing the precaution of making a 
bevelled cut through the bone, by using only moderate 
blows and driving the instrument alternately for a short 
distance on each side. The second danger of extensive 
fracture may be averted by being cautious to see after each 
stroke on the punch that it has not slipped inward along 
the median side of the tooth, pressing the internal plate 
away from the tooth and tending to produce a longitudinal 
fracture nearly or quite as long as the dental arcade. 
Careful digital exploration in the mouth may discover this 
fracture while still " simple ", but a stroke or two more will 
convert it into the very much more serious " compound " 
fracture opening into the oral cavity. Keeping one hand 
constantly in the mouth at the point of impact is always 
desirable as a precautionary measure. 

Transverse division of the tooth while yet in situ by 
means of the bone chisel, as above described, is a great 
safeguard against fracture of the jaw by lessening the force 
required in repulsion and by the removal of the tapering 
fang, which then leaves a more secure base for the punch 
to act upon. It should never be forgotten that the impact 
from the punch must always be as nearly parallel to the 
long axis of the tooth as is possible. 



14 TREPHINING THE FACIAL SINUSES 

The fracture of the superior maxilla and bony palate is 
not so probable as the preceding and is preventable by mod- 
erate care in the denuding of the tooth before punching, by 
comminution of the tooth in proper cases, by the careful 
adjustment of the punch and by applying the force in the 
proper direction. 

Literature. Odontomes, Sir Bland Sutton, Jour. Comp. 
Med. and Vet. Arch, Vol. XII. p. i ; A Clinical Study of 
Odontomes, W. L. Williams, Am. Vet. Review, Vol. XV, 
p. i ; Notes on Odontomes, do ; Am. Vet. Rev. Vol. XXIII, 
p. 82 and Oest. Mon. Thierheilkunde, Bd. XXIV, s. 122. 



TREPHINING THE FACIAL SINUSES 
Figs. 3-11 

The facial sinuses of the horse constitute an exceedingly 
intricate and extensive group of cavities, communicating 
more or less freely with each other or with the exterior 
through the medium of the upper air passages, of which 
they are to be regarded as a part. 

Their arrangement and relations permit them to fre- 
quently become the seat of, or central figure in, many forms 
of disease which require for their differential diagnosis, 
amelioration or cure, the operation known as trephining. 
Their extent and relation to each other and to surrounding 
parts vary greatly with age. They may also be profoundly 
changed as a result of disease, resulting not infrequently 
in the frontal, superior and inferior maxillary sinuses ceasing 
to exist as separate compartments and becoming merged 
into one vast cavity. The general position, extent and re- 
lation of these are indicated by Figs. 3-1 1. 

It is to be noted that in cross sections the superior and 
inferior maxillary sinuses appear to be reversed in relation 
to their nomenclature. It is difficult to make a cross sec- 



TREPHINING THE FACIAL SINUSES 15 

tion of these sinuses in such a manner that the antero- 
inferior extremity of the superior sinus does not show below 
and external to the inferior one. The inferior maxillary 
sinus is inferior in the sense that it is nearer to the nasal 
opening, so that with the head in a vertical position or in a 
longitudinal section, the inferior sinus is below the superior, 
while if the head be placed horizontally or a cross section 
made, a small portion of the superior sinus may show below 
the inferior. 

The uses of trephining are in a measure common to all 
the sinuses and are chiefly for the relief of empyema of the 
cavities involved, necrosis of the bony or cartilaginous walls, 
tumors of various kinds, especially dental in the young and 
malignant growths in the old, foreign bodies in the sinuses, 
differential diagnosis of diseases of this region, etc. 

Veterinarians trephine the sinuses by two fundamentally 
different plans ; with and without excision of the cutaneous 
disk corresponding to the piece of the bone removed. The 
first is generally used in Great Britain and North America, 
while the last is the prevailing method in continental 
Europe and other parts of the world. The reasons assigned 
for these variations in method are conflicting. To us there 
seem to be adequate reasons for preferring the excision of 
the cutaneous disk. We regard as the chief considerations 
in an operation the following : the reduction of infection to 
a minimum ; the prevention of pain during the operation 
or the after-treatment ; the reduction of the scar to a mini- 
mum ; rapidity and certainty of recovery ; convenience in 
operating and dressing. Inevitably a septic operation, the 
degree of infection is largely dependent upon the area of 
the wound, the facility for maintaining cleanliness and the 
degree of disturbance to the tissues while being dressed. 
The wound area in the bone is alike in all cases but that in 
the skin varies greatly. If we compare the usual European 
technic with that given below we would find the wound 



16 TREPHINING THE FACIAL SINUSES 

area approximately 2.2 sq. in. in the European method, 
while in the other we have only about .44 sq. in., or pro- 
portionately the wound area in the soft tissues in the two 
operations would be as 5 : 1. 

It is very evident that the technic given below affords 
immeasurably better facility for maintaining cleanliness in 
the wound and a minimum amount of insult to the tissues 
in the process of dressing. 

The amount of pain caused in the operation, which should 
be eliminated by local anaethesia, depends chiefly upon the 
extent of the skin incision which is essentially equal in the 
two plans, so that the only difference would be in the 
dissection of the skin from the bone in the European 
operation. The pain caused in dressing must be greater in 
the European method because the detached, overhanging 
skin must be moved and disturbed each time causing pain 
and inviting infection. The question of pain in dressing 
must always be seriously considered as it not only affects 
the time required for dressing and its efficacy, but has an 
important relation to the docility of the animal after re- 
covery, some horses having their dispositions permanently 
ruined by the irritation due to the oft repeated painful 
dressing of wounds. 

The cicatricial contraction of the tissues of the horse is 
so great that the removal of a circular disk of skin ^ to 1^ 
in. in diameter on the face does not leave a visible scar sc 
that the question of blemish falls back upon that of infec- 
tion, which, as asserted above, is far more probable in the 
continental European method. 

The rapidity and certainty of recovery are dependent 
upon the considerations above discussed. The removal of 
the cutaneous disk is certainly easier and quicker than the 
other method. The convenience for dressing is'evidently 
superior when the English and American method is used. 

The opening of the sinuses into the nostrils is based upon 



TREPHINING OF THE FRONTAL SINUSES 17 



the surgical principle that suppurating cavities should be 
provided with ample drainage from the most dependent 
part. The direction to leave the external wound open, at 
first thought, seems antagonistic to general surgical princi- 
ples but it should be remembered that the wound consists 
only of the incision through the skin, connective tissue and 
bone, penetrating a suppurating cavity, and that any object 
which we can place in this opening can only serve to dam 
back the secretions of the cavity and can not prevent them 
from coming in contact with the wounded surface. It must 
further be regarded that the respiratory mucosa of the 
upper air passages is not irritated or injured in an) T 
manner so far as we can observe clinically by the direct 
admission of air into them through a trephine, or other 
artificial opening, but, on the contrary, the suppuration in a 
sinus is constantly aggravated by the retention of the pus 
and exclusion of air, and recovery is facilitated by thorough 
drainage and aeration. 



3. TREPHINING OF THE FRONTAL SINUSES 
Figs. 3-11 

Uses. Fracture of the bony walls, necrosis, tumors. 

The ample communication below with the superior max- 
illary sinus (See FE. Figs. 5 and 6) prevents the accumu- 
lation of pus or fluids in the frontal sinuses even if formed 
therein unless the superior maxillary sinus first becomes 
filled and the contents back up into the latter. In empy- 
ema of the frontal sinuses, trephining of them alone can 
not give relief, but calls for a repetition of the operation on 
the maxillary sinuses. 

Instruments. Razor, scissors, convex scalpels, artery 
forceps, teuacula, probe, trephine, curette, gouge, Luer's 
sharp bone forceps (rongeur forceps), hammer, chisel, 



18 TREPHINING OF THE FRONTAL SINUSES 



probe pointed bistoury, dressing forceps, disinfecting and 
dressing materials. 

Technic. The operation may be performed upon the 
standing animal with the aid of local anaesthesia of the 
skin, the bone having virtually no sensation. Restless 
animals may be further secured with the twitch, in the 
stocks, upon the operating table or by casting on the sound 
side. 

Clip and shave the hair from the region of the frontal 
bone at that point which the operator has reason to believe 
is nearest the center of disease. The highest point at which 
the sinus may be trephined is indicated by F in Fig. 3. At 
this point the sinus is very shallow, its floor consisting of 
the cranial plate of the frontal bone. The most central 
portion of the cavity is reached by trephining on a level 
with the inferior border of the orbital cavity on the lines 
FE, Figs. 5 and 6. Trephining at this point gives the 
operator access to the superior maxillary sinus, SM, Figs. 
4-6, through the fenestrum, FE, Figs. 5 and 6. The 
lowest and generally most essential point for trephining is 
at ST, Figs. 4 and 5, where the opening affords free drain- 
age externally from the most dependent part of the cavity 
and at the same time offers ample opportunity for securing 
dependent nasal drainage by breaking through the superior 
turbinated bone at ST, Figs. 4, 5 and 11. 

By consulting Figs. 7-9, it will be seen that after reach- 
ing the level of the nasal septum, a trephine opening im- 
mediately against the median line like that at F, Fig. 3, 
would wound the septum and superior turbinated bone and 
penetrate the nasal cavity. Consequently the operator 
must avoid making the trephine opening in this region near 
the median line, but must keep 1^ to 2 inches laterally 
therefrom. 

With a heavy convex scalpel, make a circular incision at 
the desired point as large as the area of the trephine, 




FIG. 3. 
Trephining the Facial Sinuses. 
F, highest point at which an opening may be made into the frontal 
sinus without wounding the cranium and brain ; X, opening into 
nasal sinus ; SM, opening into superior maxillary sinus; I M, open- 
ing into external portion of inferior maxillary sinus; IM', opening 
into the median portion of the inferior maxillary sinus. 



20 TREPHINING OF THE FRONTAL SINUSES 

directly through the skin, subcutem and periosteum down 
to the bone and remove in one piece the entire mass of 
encircled soft tissues by seizing the skin with a tenaculum 
and forcibly separating the periosteum from the bone with 
the scalpel or bone chisel. Control the hemorrhage. 

With the center-bit of the trephine extended, place it accu- 
rately upon the denuded area perpendicular to the surface 
of the bone and grasping the handle firmly, turn it to and 
fro until the bit has penetrated the bony plate and the saw 
has cut a distinct groove to serve as a guide, when the center- 
bit should be retracted and the operation continued until 
the disc of bone is detached, being careful to maintain the 
trephine perpendicular to the surface. The operation is 
facilitated by grasping the shaft of the trephine between 
the thumb and fingers of one hand, constituting a support 
in which it may turn back and forth. The pressure under 
which the trephining is carried out must not be too great 
or the instrument may become wedged and broken. 

When the bony plate which has been isolated begins to 
loosen, remove the trephine and break or pry out the piece 
of bone with the bone gouge or chisel. Smooth any uneven 
edges of bone with a heavy scalpel or by re-inserting the 
trephine and using it as a rasp. The abnormal contents of 
the sinus may now escape through the opening or be re- 
moved with the curette, forceps or scissors, and the cavity 
irrigated with an antiseptic fluid. 

Leave the trephine wound entirely open and irrigate the 
sinuses daily with antiseptics. 

The frontal being in free communication below with the 
superior maxillary sinus, the irrigating fluid falls directly 
into the latter until it becomes filled. The superior turbi- 
nated bone of the same side, forming the median wall of 
the frontal sinus, is commonly perforated by necrosis in 
cases of serious disease, establishing a communication be- 
tween the frontal and nasal cavities, through which pus 
and irrigating fluids readily escape into the nostril. 




FIG- 4. 

Trephining of Facial Sinuses. 

Right side of face, viewed laterally, showing extent and relations of the sinuses. O. orbita 
cavity: SM, superior maxillary sinus; l.M", median portion of inferior maxillary sinus; NC, 
nerve conduit of superior maxillary trunk of the trifacial: IM. laterial portion of inferior 
maxillary sinus: F, frontal sinus; ST, opening through superior turbinated hone for the 
establishment of drainage from the frontal and superior maxillary sinuses into the nasal pas- 
Sage; IT, opening through inferior turbinated bone for the establishment of drainage from 
the median portion of the inferior maxillary sinus into the nasal cavity. 



22 TREPHINING OF THE FRONTAL SINUSES 

It has been assumed that pus or other contents in con- 
siderable quantity might pass from the superior maxillary 
sinus into the nasal cavity through the normal communi- 
cating slit between the two cavities, but a careful study of 
the anatomical arrangement of these parts, opposite N, 
Figs. 7-10, shows very clearly that this is impossible as the 
margin of the slit acts as a valve and closes it when pressure 
is applied from within. 

In order to prevent the aspiration by the patient of the 
contents of the sinuses, whether pus, blood or irrigating 
fluids, and to facilitate their escape from the nostril, any 
irrigation on the recumbent animal should be carried out 
with the poll elevated and the nose depressed. 

By studying Figs. 4-10 it will be seen that any collec- 
tion of pus or other pathologic contents in the frontal sinus 
at F will result in poor drainage so far as may be obtained 
by trephining through the external wall only. The drain- 
age should be completed whether the contents have formed 
within the frontal sinus itself, or have entered it through 
thefenestrum, FE, Figs. 5 and 6, from the superior maxillary 
sinuses, by making an artificial communication through 
the turbinated bone between the frontal sinus and the nasal 
fossa at ST, Figs. 4, 5 and 11. This is to be accomplished 
by breaking through the thin walls of the turbinated bone 
by means of a probe or other suitable instrument and en- 
larging the opening sufficiently with the probe-pointed 
bistoury or with the finger. In locating the exact point 
for making this opening in the turbinated bone, it is advis- 
able to pass a slightly curved heavy probe, a pair of long 
curved uterine dressing forceps or some other slightly 
curved and somewhat rigid instrument up the nostril to 
the operative region, and having an index finger in the 
sinus against the median wall, the movements of the sound 
can easily be felt and the wall be broken down either by 
pushing the sound up into the sinus or thrusting the finger 
downward into the nasal passage. 




NC 



FIG. 5. 
Trephining of the Facial Sinuses. 

Oblique lateral view of the face with the sinuses exposed. SM, superior maxillary sinus; IM\ 
median portion of inferior maxillary sinus; NC, nerve conduit of superior maxillary division <,4' 
trifacial nerve; 1M. lateral portion of inferior maxillary sinus; F, frontal sinus; FK, fenestrum oi 
communication between the frontal and superior maxihary sinuses; S [*, artificial opening through 
the superior turbinated bone at the lowest part of the frontal sinus establishing a free communication 
with the nasal passage; [T, artificial opening through the inferior turbinated hone at the bottom 
of the median portion of the inferior maxillary sinus, affording drainage into the nasal passage. 



24 TREPHINING THE SUPERIOR MAXILLARY SINUSES 

In order to prevent aspiration of pus, blood or other fluids 
after the perforation of the highly vascular turbinated bone, 
the animal must be allowed to get up immediately. If 
under general anaesthesia, a trachea tube should be inserted 
before beginning the operation. 

Thread a long probe with a heavy suture about 75 cm. 
long and inserting it through the trephine opening into the 
nasal passage, draw it out through the nostril and removing 
the probe, attach a strip of gauze 75 cm. long to one end of 
the suture, draw it out through the nostril and tie the ends 
together on the side of the face to prevent dislodgement. 
Retain the gauze in position for about forty-eight hours to 
insure the permanency of the opening through the turbi- 
nated bone. In case of severe hemorrhage, the nasal and 
sinusal cavities may be tamponed for twenty-four hours 
with a long strip of gauze which may be secured if necessary 
by suturing to the lips of the trephine wound. In practice 
the operation can be best carried out generally with the 
animal in the standing position under local anaethesia. In 
the standing position hemorrhage and the danger from the 
aspiration of fluids is greatly lessened. 



4. TREPHINING THE SUPERIOR MAXILLARY SINUSES 
Figs. 3-10 

Uses. Empyema, diseased teeth, odontomes or other 
tumors. 

Instruments. Same as for the frontal sinuses. 

Anatomically there are two maxillary sinuses, superior, 
SM, and inferior, IM, Figs. 3-10, separated by a thin, im- 
perforate, bony partition. This partition shifts somewhat 
in position with age and in case of disease undergoes pro- 
found changes in location. Some authors advise trephining 
directly upon the partition in order to open the two cavities 



TREPHINING THE SUPERIOR MAXILLARY SINUSES T 25 

simultaneously. In extensive disease of either sinus the 
partition between the two frequently becomes obliterated 
so that there remains but one ; in limited disease the open- 
ing of both cavities is ill advised. In extensive disease the 
existence of a partition may generally be ignored and the 
trephine opening be aimed at the probable focus of the 
malady. Should this fail to reach the desired point, 
the proper location may now be determined by digital or 
other examination through the first opening. A second 
operation should then be made to directly reach the seat of 
the affection and if need be, a third to secure proper 
drainage. 

Shave and disinfect as much of the area as may be re- 
quired, bounded above by the inferior border of the orbital 
cavity, laterally by the zygomatic ridge, inferiorly by the 
lower end of the zygoma, and medianwards by the middle 
line of the face. Determine the proper point for operation 
by percussion or otherwise. If it be desired to enter only 
the superior maxillary sinus, SM, Figs. 3-10, locate the 
opening beneath the orbital cavity and in front of the zygo- 
matic ridge, SM, Fig. 3, or at any point directly beneath this 
to midway between SM and IM, Fig. 3, at about the level 
of the dotted line IM'. 

The trephining is carried out as described for the frontal 
sinuses on page 17. After the trephining has been com- 
pleted remove any purulent collection or tumors or carry 
out any other necessary operation in the affected sinuses, 
and after cleansing, if the trephine opening does not insure 
perfect drainage of the lateral sac, either lower it by cutting 
away its inferior border with the bone forceps, or make a 
second trephine opening at the necessary point. 

Since empyema of the superior maxillary sinuses is due in 
the vast majority of cases to infection derived from diseased 
teeth or dental alveoli, it is essential after the sinus has been 
opened that the operator search carefully and minutely over 



SM 




FIG. 6. 
Trephining of Facial Sinuses. 

Frontal view of right side of face with sinuses exposed. SM, 
superior maxillary sinus ; IM', median portion of inferior maxillary 
sinus ; IM, lateral portion of inferior maxillary sinus ; F, frontal sinus ; 
FE, communication between the frontal and superior maxillary sinuses. 



TREPHINING THE SUPERIOR MAXILLARY SINUSES 27 

the alveoli of the molars for naked, eroded tooth fangs or 
for fistulse leading down into the dental alveoli. If dental 
disease is recognized, the trephining of the sinus is to be 
supplemented by repulsion of the offending tooth as 
described on page 7. 

Under the influence of disease, the sinuses may extend far 
beyond their normal location or may contract or become 
largely obliterated by being filled with new bone or soft 
tissue. The median portion of the superior maxillary sinus 
on the inner side of the bony conduit of the trifacial nerve, 
NF, Figs. 4-10, can not always be completely drained 
through the opening SM, Fig. 3. Provision for this 
must then be made by trephining into the lower part of the 
frontal sinus and thence breaking through the superior 
turbinated bone, ST. Figs. 4 and 5, into the nasal passage, 
or at times it may be feasible to break through the inner 
wall of the superior maxillary sinus on the median side of 
the nerve conduit into the nasal cavity. If the inferior 
maxillary sinus is also involved, good nasal drainage may be 
had by breaking down the inter-sinusal partition and then 
penetrating the inferior turbinated bone at IT, Figs. 4 and 
5, and inserting through this opening a long and thick strip 
of gauze which is brought out through the nostril. The 
ends of the gauze are then tied together on the side of the 
face to prevent displacement. Retain this in position, re- 
newing daily until the permanency of the opening is assured. 

It generally occurs in extensive empyema of the sinuses, 
that an opening in the turbinated bone takes place by 
necrosis and in some cases affords the desired drainage 
while generally the pathologic opening is so placed that it 
is incomplete. 

Leave all wounds entirely open and irrigate daily with 
antiseptic solutions. 

Dangers. Care must be exercised not to injure the 
superior maxillary division of the trifacial nerve, NF, Figs. 




FIG. 7 

Trephining of Facial Sinuses 

Cross section of the right half of the head of a horse at the posterior 
border of the last molar. F, frontal sinus ; IM, lateral portion of 
inferior maxillary sinus at extreme posterior or superior part ; IM', 
median portion do. ; N, nasal chamber opposite the communication 
between it and the superior maxillary sinus ; NF, conduit of superior 
maxillary branch of the trifacial nerve ; SM, superior maxillary sinus ; 
M 3 , fragment of last molar. 



TREPHINING THE INFERIOR MAXILLARY SINUS 29 

4-10, either in trephining or after the sinuses have been 
opened. The bony conduit of this nerve is in rare cases 
entirely resorbed by pressure from dental cysts or other 
causes, leaving it stretched across the cavity as a white 
nacrous cord, intensely sensitive. Any injury to this nerve 
causes intense pain and renders the animal very resistant to 
the necessary manipulations in the after care of the wound 
and may leave the patient permanently nervous about the 
handling of its face. 

Hemorrhage is generally not severe and may occur from 
the skin, where it may be readily controlled by compression 
or ligation ; from the intra-osseous vessels, where it may 
be checked by pressure with absorbent cotton, by pushing 
a small portion of cotton into the channel of the vessel with 
a needle or tenaculum or by plugging the vessel with a 
conical piece of wood ; from the wounded turbinated bones, 
where it may be stopped by packing with gauze. These 
tampons should be removed after twenty-four hours. 



5. TREPHINING THE INFERIOR MAXILLARY SINUS 
Figs. 3-11 

Uses and Instruments. Same as in the preceding. 

Anatomical Outline. The inferior maxillary sinus is an 
exceedingly irregular cavity, differing in details of form 
and extent in individuals and at various ages. As shown 
in the illustrations, its disposition might be compared to a 
pair of saddle bags hanging over the nerve conduit, the 
lateral and median chambers not very unlike in extent. 
As suggested in Figs. 4, 5, the floor of the lateral cavity is 
broken up by irregular bony septa, which in some cases cut 
the sinus up into quite separate cavities. Sometimes it 
extends downward barely below the end of the zygoma, 




FIG. 8 

Trephining the Facial Sinuses 

Cross section of the left side of the head of an aged horse at the 
second molar, seen from the front. F, frontal sinus ; N. nasal sinus, 
opposite the communication between the nasal and maxillary sinuses ; 
IM, lateral portion of inferior maxillary sinus ; IM', median 
portion of inferior maxillary sinus ; SM, superior maxillary sinus ; 
NF, superior maxillary division of trifacial nerve in its bony conduit ; 
SZ, subzygomatic artery ; P, palatine artery ; M2, second molar. 



TREPHINING THE NASAL FOSSAE 31 

at other times it reaches down below the intra-orbital fora- 
men. There is hence no rule by which the operator may 
at all times make his opening precisely at the lower ex- 
tremity of the sinus. 

TechniC. The general technic is the same as for the 
frontal and superior maxillary sinuses, but two trephine 
openings should always be made. The first opening should 
be made close against the median side of the zygoma near 
its lower or nasal extremity, Fig. 3, IM, and the inferior 
border lowered sufficiently with the bone forceps to provide 
thorough drainage for the lateral compartment of the 
sinus. 

The second opening is to be made on the median side of 
the nerve conduit, NC, Figs. 4, 5, as indicated at IM' in 
Fig. 3. The location may be accurately determined by pal- 
pating with the index finger through the first opening at 
IM, Fig. 3. This compartment can not be well drained 
upon the face through either of the trephine openings, so a 
third opening, penetrating the inferior turbinated bone at 
IT, Figs. 4, 5, is essential to ideal results by affording free 
drainage into the nasal chamber. The opening through 
the inferior turbine is made in the same manner as de- 
scribed for the opening through the superior turbine from 
the frontal. Thorough search should be made throughout 
the sinus for the causes of disease. Should diseased teeth 
be present, remove these and follow by after treatment the 
same as advised for the two preceding operations. 



6. TREPHINING THE NASAL FOSSAE 

Figs. 7-10 

Uses. Operations upon the septum nasi, or the turbi- 
nated bones, or the removal of tumors or foreign bodies from 
the nasal passages. 



N- 



IM—f 



P- 




FIG. 9 
Trephining the Facial Sinuses 

Cross section obliquely downwards and backwards through the 
right half of the head of a two-year old colt at the first molar. F, 
Frontal sinus ; N, nasal passage at point of communication with the 
maxillary sinus, IM ; IM', median portion of inferior maxillary 
sinus ; SM, extreme lower end of superior maxillary sinus opened ; 
Mr, first molar; M2, second molar; P, palatine artery; SZ, sub- 
zygomatic artery. 



TREPHINING THE NASAL FOSSAE 33 

Instruments. Same as for the frontal sinuses (page 17). 

Technic. The trephining, N, Fig. 3, is carried out by the 
method described above, in the nasal bone, close by the 
median line of the face and according to indications at any 
point from a level of the dotted line, SM, Fig. 3, to the 
juncture between the nasal and pre-maxillary bones near 
the upper extremity of the false nostril. 

A study of Figs. 7-10 will show that the trephining of 
these cavities requires great care in order to avoid wound- 
ing either the highly vascular septum nasi or even more 
vascular turbinated bones. The operation should be im- 
mediately against the septum since otherwise the superior 
turbinated bone may be wounded or an important intra- 
osseus artery in the nasal bone, just above its union with 
the superior turbinated, as shown in Fig. 9, may be severed. 

If the turbinated bone is penetrated the frontal, and 
through it, the superior maxillary sinus is opened and ex- 
posed to infection with all its consequences. Special care 
is accordingly necessary that the trephining should not be 
carried too deeply, that the bone be barely penetrated, and 
that the osseous disc be carefully removed in order to avoid 
the wounding of the turbinated bone, which lies in close 
proximity to the nasal bone. The operative area is narrow 
and the trephine used should not exceed 2 cm. in diameter. 

Whenever possible the operation should be carried out 
on the standing animal which decreases the hemorrhage 
and the danger from the inhalation of fluids. The hemor- 
rhage may be further controlled in operations upon the 
septum nasi and turbinated bones by spraying the parts with 
adrenaline chloride and cocaine. Even in the standing 
animal, if extensive operations are to be carried out on the 
very vascular septum nasi or on the turbine, it is advisable 
to preform trachetomy before trephining, and retain the 
trachea tube in position until all danger has passed. When 
the animal is confined in the recumbent position, the 




M : 



FIG. 10 
Trephining of Facial Sinuses 

Cross section of the left side of the head anterior to the last molar, 
and through the widest part of the inferior maxillary sinus. M 3 , last 
superior molar ; V SM, superior maxillary sinus at its anteroinferior 
extremity ; IM, inferior maxillary sinus, lateral portion ; IM', do. 
median portion ; N, nasal fossa ; S, sound lodged in lachrymal duct ; 
NF, trifacial nerve ; F, frontal sinus. 



POLL EVIL OPERATION 35 

patient's safety demands that tracheotomy be performed in 
almost all cases before any operation is begun upon the 
septum nasi or turbinated bones. After tracheotomy, 
anaesthesia may be maintained by means of an ordinary 
funnel with its tube bent at right angles and inserted into 
the trachea tube while the chloroform is dropped on a towel 
spread over the funnel mouth. After completing any 
required operation upon the septum, turbinated bones or 
other parts, hemorrhage may be controlled by packing one 
or both nasal fossae with single strips of gauze of sufficient 
size and carefully securing them by sutures to the sides of 
the trephine wound or otherwise. 



7. POLL EVIL OPERATION 



Fig. 11 



Instruments. Clipping shears, razor, sharp scalpels, one 
dozen compression artery forceps, probe-pointed bistoury, 
probe, Luer's bone forceps, bone gouge, curette, suture and 
dressing material. 

Technic. Clip the foretop and mane and shave the fore- 
head and the top of the neck back to a distance of 8 or io 
cm. or as much farther as may be required to pass beyond 
and behind the supposed extension of disease, and disinfect 
the area. Confine the animal in lateral decubitis preferably 
upon the operating table, place under complete anaesthesia 
and remove the halter or other headgear. 

With sharp scalpel make a longitudinal incision on the 
median line of the head and neck beginning at a point pre- 
sumably posterior to the diseased area and carry it over 
the poll down onto the forehead for a distance of 4 or 5 cm. 
below the foretop. Continue this incision through the skin, 
the subcutem, the adipose tissue, AT, Fig. 11, and either 
through, or passing around alongside the neck ligament, 



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38 POLL EVIL OPERATION 

LN, into the diseased area beneath the latter. Dissect the 
ligamentum nuchse away from the adjoining tissues as far 
back as diseased, divide it obliquely upward and backward 
as indicated at AA, and detach anteriorly from the base of 
the occiput. Be careful to remove every portion of the 
ligament in the area indicated and all calcareous deposits or 
other diseased tissues. 

With Luer's forceps, groove a channel about 2 cm. wide 
from behind to before directly upon the median line, through 
the occipital protuberance to the depth of about 2 cm. mak- 
ing the bottom as near as possible on a level with the wound 
in the soft tissues as indicated by the dotted line, AA. 
Using Luer's forceps as a curette, detach all vestiges of the 
neck ligament from the base of the occiput and leave the 
bone bare and smooth. If the Luer or rongeur forceps are 
not available the grooving of the occiput may be accom- 
plished with a strong curved bone gouge. Or the grooving 
of the occiput and curetting away of the attachments of the 
neck ligament to the base of the occiput may be very 
effectually accomplished with a hoof knife. Be careful to 
avoid penetrating the cranial cavity or the occipito-atloid 
articulation. If the operator is not perfectly clear regarding 
the anatomy of the parts, he would do well to have before 
him a sagittal section of the head of a horse which may 
serve as a guide. In curetting the ligamentous attachments 
from the occiput, the operator should keep the index finger 
of the left hand at the bottom of the wound, against the 
occipito-atloid ligament in order to protect it from injury. 
The operation is rendered more safe also by rigid control of 
the hemorrhage to which end he needs an ample number of 
compression artery forceps. 

Control the hemorrhage, cleanse and disinfect the wound, 
pack with antiseptic gauze and suture except at the anterior 
part, where the tampon should slightly protrude. Disin- 
fect the margins of the wound. Remove the tampon after 



DEHORNING OF CATTLE 39 

forty-eight hours and dress daily with antiseptics. The 
sutures may or may not be removed according to conditions. 
In carrying out this operation the chief aim should be to 
remove all diseased parts, to afford perfect drainage ante- 
riorly, to secure and maintain antisepsis, and to keep the 
wound directly on the median line, from which no visible 
scar will result. 



8. DEHORNING OF CATTLE 
Figs. 12 and 13 

The horns of cattle, useful as organs of offense and defense 
in the wild state, become valueless, except in appearance, 
under domestication. They detract from the docility 
and convenience of handling the animals, and render 
them less safe for man and for other animals. The develop- 
ment of the horns may readily be prevented in new-born 
calves by the timely application of caustic potash to the horn 
germ. When this is neglected and it is later desired to be 
rid of the horns, the operation designated dehorning is 
necessary. 

Dehorning is performed with either the saw or dehorning 
shears. Mechanically the saw has the disadvantage of be- 
ing slower and hence more painful to the animal. It pro- 
duces a large amount of sawdust which largely drops into 
the frontal sinuses where it may cause mechanical irrita- 
tion. It has the advantage of mutilating the arteries of the 
horn and thereby lessening hemorrhage. 

The shears, or dehorners, are generally preferred because 
the operation (regularly done without anaesthesia) is 
quickly accomplished so that the cutting pain is for a moment 
only, the cut through both the skin and the horn core is 
smoother, leaving less damaged tissue to necrose and disap- 
pear, and the wound is left free from sawdust. The shears 



40 DEHORNING OF CATTLE 

have the disadvantage of sometimes fracturing the horn core 
and of cutting the artery cleaner than the saw and thereby 
inviting greater hemorrhage. The shears are, therefore, 
preferable on the whole. In cases of emergency the saw 
may be substituted, the method of confinement and the 
point at which the horn shall be severed being alike in each 
case. 

The animal should be confined in stocks, or an ordinary or 
special stanchion, with the head firmly and securely extended. 
The securing of the head is best effected by means of a strong 
rope tied around the neck, with a loop about the nose. The 
rope does not, by this plan, come in contact with the horns 
and is not in the operator's way. 




FIG. 12. Dehorning of Cattle 

1. Posterior or main artery of horn core ; 2, anterior or lesser 
artery of horn core ; 3, 4, posterior anterior arteries of the matrix or 
corium of horn ; 5, external carotid artery. 



DEHORNING OF CATTLE 41 

The point for excision is located on the cephalic side of 
the matrix of the horn, a distance of about i to 1.5 cm. 
from the margin of the skin. There are three reasons for 
selecting this location : 

1. It is essential to include a girdle of skin of the width 
named in order to remove the matrix of the horn. If less is 
removed, horn is developed and the animal is left with un- 
sightly horny excrescences. 

2. The chief arteries of the horn core (extension of 
frontal bone) are at this point subcutaneous, can conse- 
quently retract readily and thereby exert efficient hemosta- 
tic power. They soon leave the subcutem and become 
intra-osseous as shown in Fig. 12 at 1,2 and Fig. 13 at 1, 2. 
The intra-osseous artery, when severed, cannot retract 
promptly and therefore possesses low hemostatic power, 
resulting frequently in severe, and rarely in fatal, 
hemorrhage. 

3. The horn is more easily excised at this point than 
elsewhere. If the excision is attempted through the corne- 
ous layer instead of at the point indicated, the horn tissue 
offers great resistance. The application of great force to 
overcome the undue resistance may cause extensive fracture 
of the horn core, or may bend or break the blades of the 
dehorning instrument. 

The blades of the dehorning shears should be kept sharp 
and in good condition. Dull blades fracture the horn core 
and thus delay healing, and the dullness, by increasing the 
strain, tends to break the instrument. 

Have an assistant grasp the nose firmly by means of a 
leading ring or with the fingers and steady the head. Apply 
the dehorners at that point level with the base lineofi,in 
Fig. 12 and close them promptly, completely excising the 
horn. Free bleeding generally follows but if the excision 
is made at the point indicated, the divided arteries contract 
and the hemorrhage quickly ceases. As shown in Fig. 12, 




\ ^ 



04 03 ,3 









44 DEHORNING OF CATTLE 

the matrix of the horn is supplied principally by two 
branches from the common carotid, one of which curves 
around the base of the horn in the front, the other behind. 
If one of these should be split longitudinally, the vessel 
may be unable to retract, and may bleed profusely. The 
hemorrhage may be controlled by compression forceps, by 
sutures, or by a ligature surrounding the poll and drawn 
tightly in a manner to compress the chief arteries of the 
horn as shown in Figs. 12, 13. 

If the excision has been made too peripheral and the 
intra-osseous vessel severed, the hemorrhage may be con- 
trolled by a ligature about the poll as suggested above, or 
by inserting into the mouth of the wounded intra-osseous 
vessel, a conical peg of wood and pressing it in firmly. 

Any adherent pieces of fractured bone should be removed. 
No antiseptics or other drugs or substances should, as a 
rule, be applied. The blood washes them away from the 
actual cut surfaces and they largely fall into the frontal 
cavity to cause irritation and harm. The blood and lymph 
which quickly dry constitute a splendid protective covering. 



9. LIGATION OF THE PAROTID DUCT 
Fig. 14 

Objects. The destruction of the parotid gland in case of 
incurable fistula from wounds or abscesses. 

Instruments. Razor, convex scalpel, straight probe- 
pointed scalpel, tenaculum forceps, ligation forceps, tena- 
cula, needle holder, probe, suture and dressing material. 

Technic. In case of salivary fistula, insert a probe toward 
the gland through the fistula into the duct and with a sharp 
scalpel lay the duct free for a distance of from 1 to 2 cm. on 
the glandular side of the fistulous opening. If the fistula 
has its location on the side of the cheek, cast the horse and 



LIGATION OF THE PAROTID DUCT 45 

shave and disinfect the region on the inferior maxilla where 
the artery, vein and parotid duct turn around its inferior 
border. When the operator glides his finger over the vas- 
cular region forward and backward, there is felt a resistant 
cord, the pulsating external maxillary artery about 3 mm. 
in diameter. Just behind this (towards the oral border of 
the masseter muscle) lies the external maxillary vein and 
lying more deeply between the vein and border of the 
masseter, is the parotid, or Steno's duct, covered by dense 
connective tissue. Make an incision about 4 cm. long di- 
rectly over the duct parallel to the artery through the skin 
and skin muscle. Pick up the connective tissue with a pair 
of forceps and excise it, laying the duct bare. Care is to be 
taken while manipulating the duct, not to prick the con- 
tiguous vein and cause annoying hemorrhage. 

When a salivary calculus exists which cannot be removed 
through the mouth, or there is a cystic dilation of the parotid 
duct, make the cutaneous incision at the affected point. 
After opening the canal, and removing the calculus, etc., 
close the duct wound by means of intestinal sutures in such 
a way that the external surface of the lips of the wound in 
the wall of the duct are brought in contact, or ligate the 
duct on the proximal side of the point of operation and 
thereby destroy the gland. 

Ligation of the duct is accomplished by passing a strong 
silk thread beneath it by means of a curved aneurism needle, 
carrying the ligature around the duct and tying with a sur- 
geon's knot. This destroys the gland by damming back 
the saliva until the pressure stops its function and causes 
atrophy. Disinfect the wound and close the skin by means 
of a continuous suture. 




FIG. 14 

Ligation of the Parotid Duct 

Above, Left side of head showing general topography of operative 
area. 

Below, Detail of vessels at usual operative area. 

i, Parotid duct; 2, external maxillary vein ; 3, external maxillary 
artery ; 4, retrograde branch of external maxillary vein. 



ENTROPIUM OPERATION 47 

10. ENTROPIUM OPERATION 

Instruments. Razor, scissors, convex scalpel, tenaculum 
and ligation forceps, tenacula, needle holder, needles, thread, 
absorbent cotton. 

Technic. Quiet adult horses may be operated upon in the 
standing position with the aid of local anaesthesia, other 
horses and small animals should be secured in lateral re- 




FIG. 15 

Entropium operation on the superior and inferior eyelids of the dog. 

cumbency preferably upon the operating table. Shave and 
disinfect the skin of the inverted eyelid. Grasp the skin of 
the eyelid midway between the inner and outer canthus 
with the forceps and elevate a skin fold parallel with the 
border of the eyelid to such a height that the inverted 
member assumes its normal position. Pass a finger into the 
conjunctival sac to make sure that the conjunctiva is not 
drawn into the skin fold. Clip the fold off with the scissors 
immediately below the forceps, removing an oblong piece. 
Between the border of the eyelid and that of the wound the 
skin should be left intact for at least .5 cm. Ligate or 
compress any bleeding vessels and close the wound by means 
of interrupted sutures. It is usually unnecessary and inad- 
visable to cover the parts with hood or other appliance since 
so long as the wound is healing properly the animal will not 
disturb it. 



48 TRIFACIAL NEURECTOMY 

11. TRIFACIAL NEURECTOMY 
Fig. 16 

Object. The relief of involuntary shaking of the head. 

Instruments. Razor, scissors, convex scalpel, tenacula, 
aneurism needle, compression artery forceps, needles, thread, 
absorbent cotton, a strong piece of gauze 12 cm. square. 

Technic. Secure in lateral recumbency, preferably upon 
the operating table, and produce complete anaesthesia. Re- 
move the halter, bridle, or other headgear. Shave and 
disinfect an area 8 to 10 cm. square over the infra-orbital 
foramen. Locate by touch the infra-orbital foramen IOF, 
Fig. 1 6, below the levator labii superioris proprii muscle 
and displace this slightly upward toward the median line of 
the nose until the foramen can be clearly felt below the 
muscle. With the scalpel, begin an incision somewhat 
superior to the foramen and near its nasal border and make 
a wound downward and forward in the direction of the 
commissure of the lips about 5 cm. long through the skin, 
muscle and connective tissue down to the nerve and control 
hemorrhage with the greatest care. If the larger branches 
of the glosso-facial vessels are severed they should be ligated 
or twisted. It is even better to ligate or compress these 
vessels prior to severing them. 

Hold the lips of the wound apart with two tenacula or 
by placing a strong suture through each wound margin and 
through the skin at a point 6 to 8 cm. distant and tying the 
sutures tightly, dilate the wound thoroughly and dissect 
away the connective tissue from the nerve until every part 
of it is clearly in view. Pass an aneurism needle beneath 
the nerve trunk and lifting it from the bone, make a search 
for a small artery which usually passes along beneath it 
through the foramen, and if this can be found, either ligate 
it immediately at its point of emergence and again 5 cm. 
lower down and divide between the two ligatures, or sepa- 




FIG. 16 

Trifacial Neurectomy 

LL, Levator labii superioris proprii muscle ; IOF. infra-orbital fora- 
men ; NF, superior maxillary division of the trifacial nerve. 



50 TRIFACIAL NEURECTOMY 

rating it from the nerve, protect carefully against injury. 
With a probe-pointed bistoury or scissors, sever the nerve at 
the foramen and grasping the distal end dissect away about 
5 cm. of the trunk and excise. Be very careful to include 
all branches and especially one or two superior or dorsal 
twigs which are directed upward just as they emerge from 
the foramen. After the hemorrhage has been brought under 
complete control and all blood clots have been removed, 
cleanse the wound carefully, disinfect and close with con- 
tinuous sutures. 

In order to protect this first wound during the operation 
upon the other side, take the piece of gauze mentioned 
among the needs for the operation, and folding it several 
times in a square, place it over the wound and suture it 
firmly at each corner to the skin. Turn the animal to the 
opposite side and repeat the operation on the other nerve 
except the application of the square piece of gauze which 
is here unnecessary. If circumstances will permit, it is far 
safer in actual practice to operate first upo?i o?ily o?ie side, 
allowing this to heal and then to operate upon the other side. 

As soon as the animal stands, remove the protective piece 
of gauze from the first wound, disinfect both wounds, 
and leave undisturbed to heal by primary union. Avoid 
halter, bridle or other fixtures which might injure the 
wounds after the operation. 

In some cases the operation may be performed upon the 
standing animal under local anaesthesia and whenever this 
is possible it is greatly to be preferred since the hemorrhage 
is far lessened and the danger from sepsis reduced, but with 
most affected animals the standing operation is impractic- 
able. 

Dangers. The chief danger in the operation is from in- 
fection, which causes a severe inflammation in the proximal 
end of the nerve, aggravates the symptoms and causes much 
suffering. In order to prevent infection the aseptic precau- 



TRIFICIAL NEURECTOMY 51 

tions needs to be unusually strict in every detail and the anaes- 
thesia, whether local or general, complete. Carefully avoid 
wounding the neighboring vessels and control completely 
any hemorrhage that occurs in order to avoid a blood clot 
in the wound, which always invites infection. It is of even 
greater importance, whenever practicable, that as suggested 
above, the operation be performed first on one side only, 
and when that has healed operate upon the other. In this 
way one avoids the critical danger of the infection of the 
first wound while the head of the horse is resting upon that 
side during the second operation. 

Literature. Involuntary twitching of the head relieved 
by trifacial neurectomy. W. L. Williams, Jour. Comp. 
Med. and V. A., vol. XVIII, p. 426. Involuntary shaking 
of the head and its treatment by trifacial neurectomy, do. 
Am. Vet. Rev., vol. XXIII, p. 321 and (Est. Monatsch. 
Thierheilkunde, Bd. XXIV, s. 211. 



II. OPERATIONS ON THE NECK 

12. OPENING OF THE GUTTURAL POUCHES 

Fig. 17 

Instruments. Razor, scissors, convex sharp-pointed and 
straight probe-pointed scalpels, artery forceps, tenacula, 
probe, trocar, curette, drainage tubing, suture and dressing 
material. 

Technic. I. Viborg's method. The operation is possible 
with the animal standing, but generally the patient must be 
cast or placed on the operating table and secured in lateral 
decubitis with the head extended. By extending the head 
and compressing the jugular vein, there is brought out the 
triangle immediately behind the posterior border of the in- 
ferior maxilla and below the parotid gland comprised be- 
tween the posterior angle of the inferior maxilla, the 
terminal tendon of the sterno-maxillaris muscle and the 
external maxillary vein. 

In this so-called Viborg's triangle after the removal of 
the hair and the disinfection of the skin which is maintained 
stretched, make a 5 cm. long incision through the skin and 
skin muscle immediately beneath the aforementioned tendon 
and parallel to it. In case of pronounced swelling in 
Viborg's triangle, the operator must determine the location 
for the incision by the position of the sterno-maxillaris 
muscle. The skin, subcutem and cervical fascia having 
been incised to a sufficient extent, force a passage with the 
finger or with closed probe- pointed scissors or other blunt 
instrument through the loose connective tissue on the 
median side of the parotid gland, to the guttural pouch and 
penetrate it at its lowest point with the finger or trocar. 
In order to open the empty guttural pouch as an exercise 
operation, it is desirable to grasp a portion of its wall by 
means of forceps. Through the operative wound a drainage 
tube can be introduced into the pouch, and fixed in position 




FIG. 17 

Opening of the Guttural Pouches (Hyoyertebrotomy)!According 
to Viborg and Chabert 

Head and neck of recumbent horse viewed from the side, sm, Stylo 
maxillaris muscle ; />, parotid gland ; /, guttural pouch ; k, larynx ; 
si, sterno-maxillaris muscle; r rectus capitus anticus major muscle ; 
c y external carotid artery ; e, external maxillary artery ; i, internal 
maxillary artery ; v t external maxillary vein ; s, probe penetrating 
the floor of the guttural pouch ; a, wing of atlas. 



54 OPENING OF THE GUTTURAL POUCHES 

by sutures. The opening can be enlarged in an antero- 
posterior direction to the extent of 5 to 8 cm. or large 
enough to admit the operator's hand. Through this 
enlarged wound, the operator may palpate the Eustachian 
tube and other portions of the interior of the pouch and 
perform desired operations. 

A far more common operation in veterinary practice than 
the opening of the guttural pouches, is the opening of 
strangles abscesses of the sub-parotid lymph glands, lying 
between the inner face of the parotid gland and the external 
face of the guttural pouch. The operation here used is the 
same as Viborg's for the guttural pouch but does not pene- 
trate that cavity because the inner wall of the abscess has 
pushed the external wall of the pouch inward so that the 
former largely occupies the usual location of the latter. 
The dyspnoea generally prohibits casting the animal and 
necessitates operating in the standing position. In some 
cases the dyspnoea is so severe as to demand tracheotomy 
before the opening of the abscess can be undertaken because 
the excitement aggravates the difficult respiration to the 
point of suffocation. 

II. ChaberV s method. Secure the horse in the lateral re- 
cumbent position, remove the hair and disinfect the skin 
beneath the wing of the atlas. Make an incision about 1 
cm. in front of the lower half of the wing of the atlas 
and parallel to it, about 6 cm. long, extending through the 
skin and skin muscle down to the parotid gland. The in- 
cision is facilitated by rendering the skin tense with the left 
hand and care is to be taken not to wound the auricular 
nerve which passes directly along the atlas. Draw back- 
ward the posterior lip of the wound and separate with blunt 
instruments the posterior border of the parotid gland from 
the atlas, to which it is bound by loose connective tissue. 
Then draw the parotid gland forward with tenacula. At 
the bottom of the opening thus formed there is seen the 



OPENING OF THE GUTTURAL POUCHES 55 

stylo-maxillaris muscle, sm, Fig 17, lying against the 
median side of the parotid gland covered only by the 
aponeurosis of the mastoido-humeralis muscle. With the 
handle of the scalpel inclined toward the wing of the atlas, 
penetrate in the direction parallel to the long axis of their 
fibers the "aponeurotic expansion of the mastoido-humeralis, 
and the stylo-maxillaris muscles. The puncture is thus 
located between the ninth and tenth nerves on one side and 
the internal carotid artery on the other. Since the wall of 
the guttural pouch rests against the median side of the 
digastricus or sterno-maxillaris muscle, it is opened by this 
incision. The operator inserts an index finger along the 
blade of the knife at first and then withdrawing the instru- 
ment passes the other index finger also into the penetrant 
wound and by forcibly parting these, dilates it. The ab- 
normal contents are then removed by means of forceps, 
curretting and'irrigation. In order to prevent adhesion of 
the wound lips in the firmly stretched stylo-niaxillaris 
muscle, introduce a strong drainage tube into the pouch 
and fix it to the external borders of the wound by a suture. 



13. THE ROARING OPERATION 
FIGS. 18-22 

Instruments. Razor, hypodermic syringe, scalpels, tena- 
culum, artery forceps, laryngeal speculum, two long 
curved dressing forceps, hard rubber syringe with long 
pipe, two soft rubber ventricular burrs, reflecting lamp, 
razor-shaped scalpel, long angular scissors. 

The following technic has for its aim two fundamental 
objects which are to be kept constantly in mind : 

1. It is aimed to bring about a prompt, firm, complete 
and permanent adhesion of the arytenoid cartilage and vocal 
cord against the inner face of the thyroid cartilage in the 



56 THE ROARING OPERATION 

normal position of forced inspiration, so that no air can be- 
come impacted into the ventricle to force the vocal cords 
and arytenoid cartilage downward and inward to obstruct 
the free ingress of air. 

2. It is aimed to complete the operation without wound- 
ing a cartilage either in the essential operation when re- 
moving the ventricular mucosa, during the invading incision 
through the crico-thyroidean membrane, or later, should 
dyspnoea occur, by inserting the laryngeal tube through 
the existing incision instead of performing tracheotomy. 

Technic. Almost all animals are readily and by far best 
operated upon in the standing position. The animal should 
be confined in stocks, or otherwise, in such a manner that 
his head may be securely held in an elevated and extended 
position. The safety of the operator further demands that 
the patient shall be so secured that he can neither rear nor 
strike. The first is best accomplished by placing a rope or 
bar across the neck just in front of the withers. The latter 
may be attained by stretching a stout rope across in front 
of the forearms or radii. With gentle animals these pre- 
cautions are superfluous. 

Resistant animals need to be cast or confined upon the 
operating table. General anaesthesia upon the recumbent 
animal is usually unnecessary, and is only demanded in 
those cases of unusual resistance to confinement, where the 
patient may injure itself by its violent struggles. 

Ordinarily ample anaesthesia, whether from the stand- 
point of surgical efficiency or of sentiment, is obtainable by 
the use of local anaesthetics, in combination with adrena- 
lin. 

Shave and disinfect the operative area, and inject subcu- 
taneously a sufficient amount of the local anaesthetic. 

Make a longitudinal incision over the larynx through the 
skin and fascia as accurately as possible on the median 
raphe, commencing opposite to the anterior extremity of 



THE ROARING OPERATION 



57 



the thyroid cartilage and extending downward and back- 
ward to the region of the first tracheal ring. Separate the 
sterno-thyro-hyoideus muscle on the median line with the 
scalpel blade or handle as preferred. Control the hem- 
orrhage. If the operation is performed upon the standing 
animal with the aid of cocaine and adrenalin, the incision 
is virtually bloodless. 

Locate the crico-thyroidean ligament, triangular in form, 
bounded anteriorly and on both sides by the thyroid carti. 
age and posteriorly by the cricroid ring. Error may occur 
here and the space between the cricoid and first tracheal 
ring be mistaken for the crico-thyroidean ligament. This 
is readily obviated by careful digital palpation, which re- 





Fig. 18. 
Laryngeal dilator. 



Fig. 19. 

Ventricular burr of soft rubber, 
the sphere on the left having 
been covered with a thin lay- 
er of cotlon. 



58 THE ROARING OPERATION 

veals the triangular crico-thyroidean ligament with its 
rounded apex directed forward and its lateral borders 
sharply defined by the hard borders of thealae of the thyroid 
cartilage, while the base of the triangle rests upon the 
more elastic anterior border of the cricoid cartilage. 

Having carefully identified the crico-thyroidean ligament, 
place the back of the scalpel against the anterior border of 
the cricoid cartilage, accurately upon the median line, the 
point directed obliquely backwards toward the cavity of the 
trachea. Push the scalpel through the ligament into the 
laryngeal cavity, and carry the incision forward on the 
median line to the body of the thyroid cartilage. 

Detach the slotted piece from the laryngeal retractor (Fig. 
18) and insert the closed retractor into the incision through 
the ligament, the rachet end of the speculum being directed 
toward the trachea, the curved spurs on the jaws of the 
retractor resting within the cricoid ring. Open the dilator 
to the full extent of the crico-thyroidean space. Insert the 
hook of the slotted piece into the cavity of the thyroid 
cartilage and secure in position by means of the thumb screw 
as shown in Fig. 20. 

Illuminate the cavity of the larynx. In the standing 
animal, when facing good light, the natural illumination 
suffices. The illumination may be improved with the aid 
of a hand mirror. 

Excellent illumination is always available by means of a 
reflecting electric lamp. With a good lamp the illumination 
may be perfectly controlled in a dark room or in the dark- 
ness of night. When the animal is cast and turned upon 
his back, the light rays should enter the larynx from above 
obliquely downward and forward. If the operation is being 
done in the open field by sunlight, the patient's head should 
be directed away from the sun, or good illumination fails. 

Observe the motion of the arytenoid cartilages, and de- 
termine, if not previously done, whether the paralysis is 



THE ROARING OPERATION 59 

unilateral or bilateral. Inject with the hard rubber syringe 
with a long pipe into the larynx and laryngeal ventricles or 
introduce by means of swabs of cotton held in uterine dress- 
ing forceps, a sufficient quantity of the local anaesthetic and 
adrenalin to blanch and anaesthetize the mucosa. The 
ventricles are more conveniently injected if the syringe 
nozzle is bent near the tip. 




FIG. 20 

The ventricles commonly contain some mucus, which in- 
terferes with the securing of the mucosa and should be taken 
up and removed by means of a small piece of absorbent 
cotton pressed into the ventricle with the long curved dress- 
ing forceps. 

When the ventricular mucosa has been effectively anaes- 
thetized and any mucus removed, introduce the soft rubber 
burr wrapped with a single thickness of heavv, drv cheese- 



60 THE ROARING OPERATION 

cloth, or a thin layer of absorbent cotton into the ventricle. 
The naked soft rubber burr will ?iot securely grasp the ventric- 
ular mucosa, but when wrapped with absorbent cotton or with 
cheesecloth, and the ventricle properly cleansed of mucus, the 
burr grasps the mucosa promptly and firmly. While the 
metal burr, at one time used, grasps the mucosa well, it has a 
great tendency to tear and mutilate it a?id most of all it not 
infrequently wounds the perichondrium and induces a chon- 
dritis which causes the operatioii to fail. Press the burr 
gently against the bottom of the ventricle, and turn it to 
the right until the resistance indicates that the mucosa is 
securely engaged, Careful traction is now applied to the 
handle, revolving the burr now and then a trifle, until the 
everted mucosa from the bottom appears beyond the mouth 
of the ventricle. Grasp the everted portion of the mucosa 
securely with heavy curved artery forceps and continue trac- 
tion with these until the ventricular mucosa has been com- 
pletely everted. Then cut away the everted mucosa by 
excising it with the razor-shaped scalpel or by means of 
long scissors at approximately the point indicated by the 
dotted line in Fig. 22. 

While in many cases the muscles of the right arytenoid 
cartilage appear but slightly, if at all, paralyzed, experience 
teaches that it is usually best to operate upon both ventri- 
cles at once. 

(The operation may also be performed without the use of 
the ventricular burr, but it is more difficult, especially upon 
the standing animal. The technic is the same until the 
removal of the ventricular mucosa is reached, when, instead 
of the burr, the mucosa of the ventricle at its arytenoid 
border is grasped with the forceps, tension is applied, and 
the mucosa is incised along the arytenoid border and thence 
along the summit of the vocal cord. The incision is con- 
tinued at the point indicated by the dotted line in Fig. 22 
until the ventricular mucosa has been isolated from that of 



t/C ,vc 




The Roaring Operation 

FiG. 21. Longitudinal section through the ventricle of the larynx. 
A, Arytenoid cartilage ; TA, anterior fasiculus of thyro-arytenoideus 
muscle ; TA 7 , posterior bundle thyro-arytenoideus ; VC, vocal cords ; 
V, laryngeal ventricle ; T, thyroid cartilage ; E, epiglottis. 




Fig. 22. Sagittal section of the larynx. C, Cricoid cartilage. Other 
lettering same as Fig. 21. 



62 THE ROARING OPERATION 

the larynx in general. Cautiously exerting tension with 
the forceps upon the incised border of the ventricular 
mucosa, dissect it away from the loose underlying areolar 
connective tissue either with the Moeller razor-shaped 
scalpel or with a scalpel handle. (When the operation for 
roaring was introduced by the author, this technic was used 
and recommended, but later researches have convinced both 
author and collaborator that the technic now recommended 
is far superior from every point of view.) 

However the mucosa is removed, the operator should take 
care that the removal is complete, since any remnant incau- 
tiously left behind in the ventricle may prevent the desired 
adhesion of the arytenoid to the thyroid cartilage, or a small 
patch of mucosa being left deep in the ventricle may per- 
mit adhesion of other parts, imprisoning the mucous islet 
and ending in a mucous cyst. 

When the mucosa has been removed from one or both 
ventricles, all blood coagula should be wiped away, and any 
shreds of tissue removed. 

If the patient has been cast, anaesthetized and turned 
upon his back, turn him upon his side, remove the confin- 
ing apparatus, and, while he is recovering from the anaes- 
thesia, keep the laryngeal incision open and the larynx free 
from blood. The hemorrhage is greatest when the animal 
has been cast and placed under general anaesthesia, less if 
cast and the operation performed under local anaesthesia, 
and by far least of all when it is performed upon the stand- 
ing animal with the aid of local anaesthesia with adrenalin. 

As soon as the operation has been completed upon the 
standing animal, the head may be released and the patient 
returned to the stall. It may be allowed to eat or drink at 
convenience. The same is true of the patient cast for the 
operation, and only local anaesthesia applied. Patients 
cast and chloroformed should be prevented from eating or 
drinking for some hours and should be fed sparingly for 
three or four days. 



THE ROARING OPERATION 63 

During the first 48 hours after operating, the patient 
should be closely watched in reference to dyspnoea either 
from hematoma in the ventricles or from edema or emphy- 
sema of the parts. As a rule of practice, it is best to insert 
into the wound a laryngeal tube which should be fixed 
securely to the margins of the external wound by means of 
heavy sutures, and further security given by passing strong 
tapes about the neck and tying firmly. 

Ordinarily the ventricular wounds should not be disturbed 
after the operation. The external wound should be dressed 
daily with antiseptics till healed, a period of about three 
weeks. Horses used for ordinary work purposes may 
usually be returned to their work after five to six weeks. 



14. TRACHEOTOMY 
Fig. 23 

Instruments. Razor, scissors, convex scalpel, tenacula, 
tenaculum and ligation forceps, trachea tube, and suture 
material. 

Technic. In the superior third of the cervical region, in 
the neighborhood of the fourth to the sixth tracheal ring, 
shave and disinfect the skin on the anterior surface of the 
neck to the extent of 10 cm. long by 5 cm. wide. The 
operation is best performed upon the standing animal with 
the head extended. In lateral decubitis the operation is 
carried out with some difficulty, and generally the operator 
fails to get the incision on the median line. The operator 
stands before the right shoulder of the horse with an assist- 
ant opposite him. 

Render the skin tense along the median line of the 
trachea with the left hand and then make a drawing cut 5 
to 8 cm. long from above to below with the scalpel. The 
incision should be made carefully upon the median raphe of 



64 TRACHEOTOMY 



the skin, which has very little sensation and the require- 
ments for anaesthesia are small. After the skin muscle is 
cut through, in order to avoid hemorrhage, separate the 
two sterno-thyro-hyoideus muscles by means of tenacula 
along the median raphe in the white strip of connective 
tissue. The opening into the trachea may be made in a 
variety of ways. The quickest and most crude method is 
to slit it from above downward through two or three trach- 
eal rings, and pressing the several ends apart, insert the 
tube through the opening. Since the tracheal rings are in- 




FIG. 23 

Tracheotomy, s, Sterno-thyro-hyoideus muscle ; t, trachea ; 

sch, mucous membrane of the posterior wall of the trachea ; 

/, interannular ligament. 
complete, being open on their dorsal surfaces, cutting 
through the ventral portion divides each ring into two sepa- 
rate parts and their being pushed apart distorts them and 
tends to the causation of chondritis and collapse of the 
trachea, a danger which increases with the duration of 
time that the tube is maintained in position. The severing 
of tracheal rings in tracheotomy is therefore most suitable 
for hurried operations in impending suffocation where the 
tube will probably be needed for a short time only. 



INTRA-TRACHEAL IRRIGATION 65 

A second method of operation, illustrated in Fig. 23, con- 
sists in making a transverse incision through the inter- 
annular ligament between the two last exposed tracheal 
rings the length of the diameter of the tube to be inserted. 
Make a perpendicular incision upward from each end of 
this at a point 1 to 1.5 cm. from the median line through 
one or two tracheal rings, according to the size of the tube. 
With forceps or tenaculum grasp the segments of partially 
detached cartilage and remove them by cutting through the 
inter-annular ligament. 

A third, and to us preferable, method is to insert a narrow- 
bladed scalpel transversely at about the lower third of the 
lowermost bared tracheal ring and cutting outward and 
upward in a curved line, to pass through the first inter- 
annular ligament and continue into the succeeding segment 
until near its superior border, when the incision is curved 
downward to eventually reach the starting point, the isolated 
section of the trachea being securely grasped with a pair of 
forceps before its excision is completed. By this method 
no tracheal ring is severed. 

The trachea tube is to be removed and cleansed daily as 
long as its use is necessary, and when discontinued the 
wound should be left open and dressed with antiseptics. 



15. INTRA-TRACHEAL IRRIGATION 

Objects. The washing out of oils or other insoluble or 
irritant substances accidentally introduced into the trachea 
and bronchi while drenching or otherwise, and the disin- 
fection of the trachea and bronchi. 

Instruments. Same as for tracheotomy, and a gravity 
irrigating apparatus fitted with 3 m. of rubber tubing about 
1 cm. in diameter, 5 liters of .6 per cent, sodium chloride 
solution at a temperature of 37 to 39 C. In cases of sup- 
purative bronchitis, peroxide of hydrogen may be added 
to the solution. 



66 INTRAVENOUS INJECTION 

Technic. Operate on the standing animal. Perform 
tracheotomy (page 6.3). Elevate the gravity apparatus 
containing the irrigating fluid 1 lo 2 m. above the patient, 
have the animal's head slightly elevated, insert the free end 
of the rubber hose in the trachea tube and let the fluid flow 
into the trachea in a moderate stream until the animal makes 
expulsive efforts, when the inflow is stopped and the animal 
permitted to lower his head and expel the fluid, then raise 
the head again and repeat until the fluid is expelled clear. 
Repeat the operation according to requirement. 



16. INTRAVENOUS INJECTION 
Fig. 24 

Instruments. Scissors, hypodermic syringe. 

Technic. The operation is performed on the standing 
animal on either jugular vein at about the juncture of the 
upper and middle thirds of the neck ; to most operators the 
right jugular is the more convenient. At the place desig- 
nated, the subscapulo-hyoideus muscle lies between the 
jugular vein and the carotid artery and affords some pro- 
tection against injury of the latter. After clipping the hair 
and shaving, the skin should be carefully disinfected pre- 
ferably with tincture of iodine. The vein lies in the jugular 
groove between the mastoido-humeralis and the sterno- 
maxillaris muscles, covered only by the skin and skin muscle. 

Stand by the shoulder of the horse and compress the 
jugular with the thumb as shown in Fig. 24 or with the 
second to the fourth fingers, in which case the ball of the 
thumb rests on the mastoido-humeralis muscle. The vein 
becomes filled above the point of compression in the shaved 
area and stands out as a swollen cord. In fleshy-necked 
horses efficient compression is more readily attained if the 
head is somewhat elevated and extended by an assistant. 
If the vein cannot be made prominent in this way, the 



INTRAVENOUS INJECTION 67 

compression should be alternately applied for a time and 
then withdrawn suddenly when the course of the vein reveals 
itself by a wave-like movement along the jugular groove. 
In cattle, digital compression of the jugular is not always 
efficient in causing distension. It is more practical to dis- 
tend the jugular bypassing a looped cord around the base 
of the neck and drawing it tightly. The very conical neck 
of the cow tends to cause the cord to slip forward and loosen, 




Intravenous Injection 

which may be obviated by having an assistant grasp the 
cord at the top of the neck and, drawing backward, hold it 
in place. A very efficient method for distending the jugu- 
lar of the cow is to stretch a strong cord tightly between 
two posts at the height of the base of the neck, lead the 
animal against it and secure the head firmly to a post in 
front sufficiently tight to cause the lower part of the neck 
to press firmly against the cord. 



68 PHLEBOTOMY 



Just above the point of compression, the vein is the most 
fully distended and firmly fixed. After testing the hypo- 
dermic needle to see that it is open, hold it between the 
first and second fingers while the thumb covers its basal 
opening and thrust it through the skin, cutaneous muscle 
and jugular wall, in the direction of the vein obliquely for- 
ward and upward i to 2 cm. deep, so that the point of the 
needle enters the vessel at its most distended part. In this 
way it is easy to prevent injury to the median wall of the 
vein. If the vein has been properly punctured, blood will 
flow from the needle upon the removal of the thumb. If 
the vein is not entered at the first attempt, the needle should 
be partly withdrawn and then pushed in again in a slightly 
different direction. 

Be careful that the hypodermic syringe contains no air. The 

material to be injected should be warmed to approximately the 
body temperature. The syringe is then connected with the 
needle and the contents slowly discharged into the vein. In 
withdrawing the needle be careful to press the skin firmly 
against the underlying part. The omission of this precau- 
tion frequently results in the formation of a subcutaneous 
hematome. 

17. PHLEBOTOMY 
Fig. 24 

Instruments. Razor or scissors, lancet, phlebotomy tro- 
car, pins, suture material. 

Technic. Phlebotomy may be performed on either jugular 
vein. The operation is preferably carried out on the 
standing animal, but is not difficult when the patient is re- 
cumbent. The point of operation is at about the boundary 
line between the upper and middle cervical regions, be- 
cause it is here that the subscapulo-hyoideus muscle, which 
separates the jugular vein from the carotid artery, is most 
voluminous and consequently affords the greatest protec- 



PHLEBOTOMY 69 



tion to the latter. At this point clip or shave and disinfect 
the skin. Compress the jugular with the finger-tips or 
with the thumb as shown in Fig. 24. In fleshy-necked ani- 
mals the course of the vein may be clearly made out by 
causing its repeated distension and relaxation. In some 
very heavy-necked horses, or in very restless animals, effi- 
cient distension of the jugular is best obtained by cording 
the neck as described under " Intravenous Injection." 

a. With the lancet the operation is perferably performed 
on the right side of the neck. Compress the vein as illus- 
trated in Fig. 24, and hold the lancet between the thumb 
and index finger in such a manner that it can penetrate the 
vein only, and then push it in quickly just in front of the 
compressing thumb through the skin, subcutem and venous 
wall as deep as the fingers holding the lancet will permit. 

Hold the blade perpendicular to the long axis of the vein, 
and avoid directing the point dorsalward, which would 
endanger the superior wall of the vessel or cause the lancet 
to glide over the wall and not enter the vein. When the 
lancet has entered the vein, extend the wound somewhat 
toward the head by flexing the hand dorsally. In cattle it 
is necessary to compress the vein by means of a cord tightly 
drawn around the neck, the operator taking the same posi- 
tion as with the horse while an assistant holds the animal 
by the horns or nose, or the vein may be still more effec- 
tively distended by causing the patient to press against a 
tightly stretched cord with the base of the neck as advised 
for intravenous injection on page 67. Close the wound by 
means of interrupted or pin suture. 

b. Phlebotomy with the trocar is performed in the same 
manner as has been described for intravenous injection. So 
long as the flow of blood continues, the compression of the 
vein must not be intermitted. The phlebotomy trocar 
should be about 5 mm. in diameter. 



70 LIGATION OF THE CAROTID ARTERY 

18. LIGATION OF THE CAROTID ARTERY 
Fig. 25, 26 

Objects. The control of hemorrhage from wounds or the 
prevention of hemorrhage during the removal of tumors or 
other operations in the parotid region. 

Instruments. Scissors, scalpel, tenacula, aneurism needle, 
mouse-toothed forceps, ligation forceps, suture material. 

Technic. The operation is possible on the standing animal 
with the aid of cocaine or other local anaesthetic but it is 
preferable to confine the patient in laternal recumbency and 
anaesthetize. 

The operation is made at the same point as for phlebo- 
tomy and the same cutaneous wound, a. Fig. 25, may be 
used for this purpose. The incision should be at least 10 
cm. long, extending through the skin, fleshly panniculus 
and subscapulo-hyoideus muscles and then a passage forced 
with the fingers to the trachea. At the region of the neck 
indicated, the carotid passes along the border between the 
lateral and dorsal surfaces of the trachea, accompanied dor- 
sally by the vagus and sympathetic nerves and ventrally by 
the recurrent. (In Fig. 25, the vagus and sympathetic 
nerves, v and s, are pushed out of their normal position and 
appear ventrally to the carotid.) Pass the index finger 
over and behind the carotid until the trachea is reached, 
and encircling the inner and lower sides of the artery, 
force a way through the surrounding areolar tissue and 
draw the vessel out through the wound. As a rule the 
carotid is still loosely surrounded by connective tissue, which 
comes from the deep fascia of the neck and in which also 
the three above-mentioned nerves are found. These nerves 
must be carefully separated from the carotid and must on 
no account be included in the ligature. If it is desired to 
permanently destroy the vessel, ligate the carotid twice with 
an interval of about 2 cm. between the two ligatures and 





m/ 



FIG. 25 

a, Ligation of the common carotid artery ; 6, Esophagotoiny. 



72 LIGATION OF THE CAROTID ARTERY 

divide the artery midway between them. The second liga- 
ture is necessary in order to prevent hemorrhage from the 
distal end through collateral anastomoses and it is essential 
to sever the artery when permanently ligated, in order to 
avoid its rupture by the stretching of the undivided carotid, 
during movements of the neck, where the nutrition has 
been cut off at the point of ligation. Provide drainage for 
the wound and suture the muscle and skin. 



19. ESOPHAGOTOMY 
Fig. 25, 27 

Instruments. Razor, scissors, convex scalpel, straight 
probe-pointed bistoury, tenacula, artery forceps, absorbent 
cotton, suture material. 

Technic. The operation can be carried out on the stand- 
ing or the recumbent animal. At its origin the oesophagus 
lies above the trachea somewhat to the left of the median 
line, and as it descends it gradually deviates to the left until 
in the lower cervical region it lies down along the left side 
of the trachea. 

The operation is performed at any point between the 
pharynx and chest where the lodgment of a foreign body or 
other condition may demand. When the esophagus is 
empty, the practice operation is best performed in the lower 
third of the neck at b, Fig. 25. 

An incision 10 cm. long through the skin and skin muscle 
is made on the left side between the anterior border of the 
mastoido-humeralis muscle and the jugular vein. With the 
two index fingers divide the loose connective tissue down to 
the esophagus, which lies between the left scalenus muscle, 
trachea and jugular vein. Along the supero-external bor- 
der of the trachea runs the carotid artery, accompanied 
dorsally by the vagus and sympathetic and ventrally by the 



ESOPHAGOTOMY 



73 



recurrent nerves. The esophagus feels like a round muscle 
within which one can distinguish a firmer cord, the mucous 
membrane. When brought into view the organ has a pale 
red color, and it, with the trachea, is surrounded by the 
deep fascia of the neck. Pass one finger around the 




FIG. 26 

Ligation of the common carotid artery 

c, Common carotid artery ; /, jugular vein ; v, vagus nerve ; s, sym- 
pathetic nerve ; r, recurrent nerve ; p, cervical panniculus carnosus 
muscle ; m, sterno-maxillaris muscle ; st, levator humeri muscle. 

esophagus from behind, draw it away from the trachea, 
force a passage through the deep fascia of the neck and 
draw it out through the external wound. After making an 
incision through the esophageal muscle and mucous mem- 
brane, introduce a probe-pointed bistoury or a scissors 
blade into the lumen of the esophagus and split its wall. 
The mucous membrane is white and lies in thick longitudi- 
nal folds. 

When there is a foreign body in the esophagus, the 
operation is performed at the point where it is lodged, in 



74 



ESOPHAGOTOMY 



the manner described, and the incision should be made only- 
large enough to permit its removal. In diverticuli of the 
esophagus, an elliptical piece of the mucous membrane 
which has been overstretched is cut out. The esophageal 
wound is closed by a laminated suture, that is, the mucous 
membrane is united by means of an intestinal suture and 
the muscular wall closed over this. The skin and muscu- 
lar wound may either be left open or closed with the Bayer 
suture and bandaged, with a drainage tube in the lower 
angle. 




FIG. 27 
Esophagotomy 

c, Common carotid artery; J, jugular vein; o, o / , ? esophagus ; s, 
sympathetic nerve ; t, trachea ; st, mastoido-humeralis (levator 
humeri) muscle. 



III. OPERATIONS ON THE TRUNK, ABDOMINAL 
AND GENITAL ORGANS 

19. PUNCTURE OF THE CHEST 



Fig. 28 

Object. The relief of hydrothorax or pyothorax. 

Instruments. Razor, scissors, trocar, i m. of rubber 


tubing of the same size as the trocar, vessel for receiving 

the escaping fluid, dressing material. 

TechniC. Operate upon the standing animal, the point of 

operation in the horse being the seventh intercostal[space 

on the left side, and the sixth on the right. Dogs may be 




FIG. 28 

Puncture of the chest ; puncture of the intestine. 

laid upon the table. The anterior ribs are so covered by 
the shoulder that they cannot be counted from before back- 
ward and must be enumerated from behind forward. In 
the horse there are usually eighteen ribs and in the dog 
fourteen. Counting 1 1 or 12 intercostal spaces from behind, 



76 PUNCTURE OF THE CHEST 

one reaches in the horse the point of operation on the left 
and right sides respectively. Clip or shave the designated 
intercostal area immediately above the thoracic vein. Grasp 
the trocar firmly with the thumb and index finger of one 
hand at such a distance from the point as will permit the 
canula to enter the chest. After the skin over the seat of 
operation has been drawn aside by the hand, place the trocar 
at the anterior border of the rib with the point inclined 
slightly forward and with a sharp blow with the palm of the 
other hand drive the instrument through the skin, cutane- 
ous and intercostal muscles, internal thoracic fascia and 
pleura into the pleural sac. When the resistance ceases, 
the thoracic cavity has been entered. Remove the stilette 
and permit the pus, lymph, or other fluid to escape. This 
flow is at first continuous, but later becomes rythmic, 
synchronous with respiration. The intermission of the flow 
during inspiration permits air to enter the pleural cavity 
unless precautions are taken against it ; this is most readily 
obviated by slipping one end of the rubber tubing over the 
exposed part of the canula and placing the other extremity 
in the receptacle for the fluid where it will be submerged. 
This will not only prevent aspiration of air into the chest 
but will act as a siphon to aid in the withdrawal of the fluid 
from the pleural cavity. In the absence of the tubing the 
entrance of air may be avoided by closing the canula with 
the finger after each expiration. 



20. PUNCTURE OF THE INTESTINES 
Figs. 28, 29 

Object. The relief of intestinal tympany. 
Instruments. Razor, scissors, trocar. 
Technic. Puncture of the intestine is preferably per- 
formed on the standing horse but may be carried out on the 



PUNCTURE OF THE INTESTINES 77 

recumbent animal. The point of operation is in the right 
flank about equidistant from the last rib, the extremities 
of the transverse processes of the lumbar vertebrae and the 
external angle of the ilium in the standing horse ; at the 
uppermost point of the abdomen in the recumbent animal, 
that is, at the most prominent part of the distension. After 
the skin at this place has been clipped or shaved and disin- 
fected, grasp the trocar with the index finger and the thumb 
of the left hand and holding the instrument perpendicular 
to the body surface, give it a firm, quick blow with the 
palm of the right hand and drive it through the abdominal 
wall into the intestine. 

With a properly constructed trocar of the dimensions 
suggested in Figure 29, no preliminary skin puncture with 
the lancet is required or advisable. The cutting end of the 
stilette should be very long, tapering and sharp so that it 
will cut as freely as a lancet. By performing the opera- 
tion as directed, the trocar ordinarily punctures the caecum. 




FIG 29. 

Intestine trocar with sheath. Outside diameter of canula, 3 mm., 
length of canula, 16 cm. 

Withdraw the stilette and permit the gas to escape 
through the canula. The canula may become occluded by 
particles of ingesta entering it. These should be removed 
by reinserting the stilette. The intestine first punctured 
may collapse and the flow of gas cease while the tympany 
continues in other parts ; this may be overcome by reintro- 
ducing the stilette and pushing the trocar through the dis- 
tal wall of the bowel into the intestine beyond. If this 
does not succeed, the trocar may be withdrawn and rein- 
serted in a neighboring area or, if need be, on the opposite 
side of the animal. 



78 RUMENOTOMY 



In withdrawing the canula, replace the stilette and press 
the skin against the abdomen with the thumb and finger of 
one hand while the trocar is drawn out with the other. 
This tends to prevent particles of ingesta from following 
the canula out of the intestine and becoming lodged at 
some point in the track of the wound to set up inflamma- 
tory processes there. 

Before introduction, the trocar should always be rendered 
sterile but should not bear irritant antiseptics, which be- 
coming lodged in the wound tend to irritate the tissues and 
produce abscesses. Puncture of the intestine is so often 
extremely urgent that deliberate aseptic precautions are 
not always practicable and trocarization only too frequently 
results in abscesses in the abdominal wall. Its prevention 
must depend chiefly upon the disinfection of the skin and 
instrument. It becomes important to use an instrument 
which is clean in advance. If the one shown in Fig. 29 is 
well disinfected after using and the sheath is filled with 
alcohol before it is screwed on, the instrument will remain 
sterile until it is again unsheathed when the alcohol will 
quickly evaporate and leave the trocar aseptic. 



21. RUMENOTOMY 

Objects. The surgical evacuation of the rumen when 
overfilled and not subject to relief by medication ; an ex- 
ploratory operation for aid in diagnosis ; the removal of 
foreign bodies from the rumen and reticulum. 

Instruments, etc. Clippers, razor, local anaesthetics, hypo- 
dermic syringe, scalpels, heavy curved artery or dressing 
forceps (6 to 8 pairs), scissors, assorted needles suitable for 
suturing rumen, peritoneum, muscles and skin, assorted 
catgut, and silk or linen sutures, needle forceps, sterile 
gauze. 



RUMENOTOMY 



79 



Control Of Patient. In many cases of overfilling of the 
rumen, the patient is unconscious and paralyzed so that 
neither restraint nor anaesthesia is indicated. In most 
other cases, rumenotomy may be performed on the standing 
animal, in stocks or restrained with leading ring in the 
nose. Very resistant animals may require confinement in 
lateral recumbency on the right side with the fore feet 
stretched forward and the hind ones backward. 




FIG. 30. 

Rumenotomy showing location of incision, with incised walls of 
rumen drawn out through laparotomy incision over the protective 
_gauze and held by forceps. 

The operative area should be clipped, shaved and disin- 
fected. Local cutaneous anaethesia should be induced by 
subcutaneous injections at short distances along the line of 
intended incision. The muscular walls should later be 



RUMENOTOMY 



anaesthetized. They are almost without sensation except 
where the larger sensory trunks of the part are encoun- 
tered. The needle for hypodermic injection needs to be 
very sharp in order to penetrate the dense, thick skin. A 
small, short, reinforced needle is best suited for the pur- 
pose. General anaesthesia is not usually prudent for 
rumenotomy because when the rumen is distended with 
food or gas, or has for any reason lost its tone, passive 
regurgitation of food occurs, with inhalation when it 
reaches the pharynx. Later, inhalation pneumonia occurs. 




■ x 



FIG. 31. Sutures in the Rumen illustrating 3 Layers 

i. Third layer of sutures burying the second, the last one laid but 
not tied ; 2, second layer burying the third layer, 3. 

When satisfactory local anaesthesia has been induced, 
make a cutaneous incision in the left flank 7 to 10 inches 
long, beginning at a point about equidistant from the lateral 
processes of the lumbar vertebrae, the external tuberosity 
of the ilium, and the last rib, and carried downward perpen- 
dicular to the spinal column as indicated in Fig. 30. Fol- 
lowing this, a second incision of the same length shou Id b e 
made on the central line of the gaping cutaneous wound 




FIG. 32. Detail of Sutures in Rumen 

i. Third layer of sutures burying the second, the last suture re- 
maining untied ; 2, second layer of sutures burying the first layer, 3. 



82 RUMENOTOMY 



through the oblique muscles of the abdomen. It should 
begin at the upper commissure of the gaping skiu wound 
and follow a line equidistant from the wound margins to 
the lower commissure. Finally the peritoneum is to be 
picked up with forceps, punctured carefully with a scalpel, 
and the opening sufficiently enlarged. 

Another and probably preferable plan for making the 
laparotomy wound is to incise the skin as directed in the 
preceding paragraph, and then separate the external oblique 
muscle obliquely downward and forward between its muscu- 
lar bundles, and the internal oblique in a corresponding 
manner obliquely downward and backward, the two pene- 
trations crossing in their middle, X-formed. The peri- 
toneum is then incised as in the preceding plan. By this 
technic, suturing of the peritoneum and muscles after com- 
pleting the operation is quite unnecessary. Only cutaneous 
sutures are advisable. 

If the rumen is distended with gases, liquids, or solids, 
it immediately prolapses somewhat through the laparotomy 
incision. The margins of two or more thicknesses of sterile 
gauze should now be introduced between the rumen and the 
wound margins as illustrated in Fig. 30. Make an incision 
through the walls of the rumen 6 to 8 inches long, imme- 
diately beneath, and parallel to, the laparotomy wound. 
Seize the lips of the wound in the rumen promptly with 
four heavy artery or dressing forceps, one upon either lip at 
the lower commissure, the other two at the upper 
angle. By drawing steadily upon the forceps, assistants 
may draw the invaded portion well out of the wound as 
shown, and can hold the walls of the rumen backward, 
forward and downward in such a manner that no aliment 
can readily escape and drop into the peritoneal cavity. 
In default of needed assistants, the operator may make a 
heavy fixing suture in the adjacent skin, pass the free ends 
of the suture through the forceps' handles, and tie them 



RUMENOTOMY 83 



securely in a manner to retain the lips of the rumenal 
wound in the position designated in the figure. 

The operator may now introduce his hand and arm freely 
into the rumen, can remove part or all of the ingesta as may 
be desired, and search the interior of the rumen and reti- 
culum for foreign bodies or other evidences of disease. 

Having completed the examination and applied any 
therapeutic agent advisable, carefully wash away any 
ingesta which has escaped from the rumen. The wound in 
the rumen is then to be sutured, using the Lembert type 
as shown in Figs. 31, 32. Heavy silk or linen should be 
used and care taken not to pass the suture into the rumenal 
cavity but only through the serosa and musculosa. If they 
penetrate the rumenal cavity, the digestive juices act 
quickly, destroy them and permit the wound to reopen. 
The closing of the wound in the rumen should not be in- 
trusted to a single row of sutures, but instead should have 
three separate sets of the same material applied in the same 
manner, the second set burying the first, and the third 
burying the second, as indicated in Fig. 32. The third 
row of sutures may be of catgut having an absorbable 
period of 20 days if preferred. The lips of the rumenal 
wound may be conveniently held with the aid of heavy 
fixation sutures below and above the lower and upper 
wound commissures respectively, similar to the plan for 
fixing the intestine as shown in Fig. 34a, page 86, and by 
having an assistant hold these firmly. 

The suture area may now be carefully wiped clean and 
permitted to drop away into the abdomen. 

The margins of the peritoneal wound are next to be 
grasped with forceps and sutured with heavy, slow-absorb- 
ing catgut. The muscle layer is best closed by means of 
very deep and quite heavy interrupted sutures, carried 
through the skin. These should be carefully laid and left 
untied until the skin wound is carefully closed bv shallow, 



84 RESECTION OF INTESTINE 

continuous or interrupted sutures. The muscle sutures 
are then to be tied over the skin sutures. By this plan the 
retaining sutures of the muscle, like those of the skin, are 
readily removed. The sutures should be left in position 
for 10 days. An antiseptic powder may be dusted over the 
wound, or in fly time, deterrent dressings containing cam- 
phor may be used with benefit. 

If the preferable plan for laparotomy, involing the x- 
formed division of the oblique muscles is used, only the 
skin sutures are to be employed. 



22. RESECTION OF INTESTINE 

Object. In cases of adhesion, ulcer, perforation, strangu- 
lated hernia, or intussusception of the intestine. 

Instruments. Razor, scalpels, scissors, artery forceps, two 
long jaw compression forceps, with four pieces of rubber 
tubing to cover the jaws of the forceps. 

Technic. The animal may be operated upon, standing or 
cast, and under either local or general anaesthesia. Cover 
the operative field with antiseptic or aseptic gauze. Make 
the laparotomy incision as directed for rumenotomy except 
that generally it should be in the right flank, whenever the 
lesion can be handled from that point. 

In case of adhesion and strangulated hernia, the incision 
may be made over any part of the abdominal cavity. Draw 
the involved portion of the intestine out through the in- 
cision and let it rest upon the surrounding gauze. Remove 
as far as possible all intestine which may be so diseased that 
it will imperil recovery, and take care that at the points of 
division there shall be a good blood supply. 

The normal intestine is clamped with the compression 
forceps, the jaws of which have been covered with rubber 
tubing to prevent injury, one pair being placed on each 



RESECTION OF INTESTINE 85 

side of the diseased tissue. The intestine is then severed 
with scissors about i cm. from the forceps toward the dis- 
eased part, care being taken not to let the intestinal contents 
enter the abdominal cavity or soil the healthy tissues. The 
incisions are carried in a v-shape, as shown in Fig. 33, into 
the mesentery for 10 or 12 cm. The mesenteric vessels may 
now be compressed with artery forceps and ligated. 




^/ 
FIG. 33. Resection of Intestines 

1. Area of intestine to be excised isolated by two compression for- 
ceps, 2 ; 3, dotted line indicating triangular portion of mesentery to 
. be removed. 

After thoroughly washing the cut ends of the intestine 
with warm, normal salt solution, the two pairs of forceps 
are brought together. One suture, with long ends, may 
now be passed through the cut edges of the mesentery close 
to the intestine and another through the edges of the con- 
vex border of the intestines, as shown at 1, 1 a in Fig. 34. 
These are to serve as stays to keep the edges of the intestine 
tense while being sutured. 

Two rows of sutures are used, the second burying the 
first. The first half of the intestine may be united with a 



86 



RESECTION OF INTESTINE 



continuous suture as shown at 2 a in Fig. 34, by bring- 
ing the two edges of serosa in apposition, and applying the 
sutures from the lumen of the intestine. The remaining 
half may be united with interrupted Lembert sutures 
placed from the outside, as in b Fig. 34. 

After the two ends of the intestine have been firmly 
united, the cut edges of the mesentery are brought to- 
gether, either with a continuous or interrupted suture. 




FIG. 34. Resection of the Intestines. 

a. Application of first group of sutures uniting tne intestine ends. 

1, 1. Tension sutures for holding ends of intestine while applying 
first sutures ; 2, continuous sutures applied from within the gut, seen 
between the non-sutured portions. 

b. Completion of the union of the intestine. 1 . First layer of Lem- 
bert sutures uniting that portion of the cut ends of intestine remain- 
ing open in a ; 2, second layer of sutures burying the first. 

c Completed operation. 1. Sutures closing the mesenteric wound ; 

2, second layer of sutures burying the first. 

Then a large supply of warm, normal salt solution is al- 
lowed to flow over the intestine until healthy contractions 
have been stimulated and a normal blood flow established. 
Should any intestinal contents have escaped into the peri- 
toneal, cavity these should be washed out by the free use 
of the salt solution. The intestine is then ready to be 
replaced in the abdominal cavity and the laparotomy wound 
sutured as described on page 78 for rumenotomy. 



SUBCUTANEOUS CAUDAL MYOTOMY 87 

23. SUBCUTANEOUS CAUDAL MYOTOMY 
Fig. 35. 

Object. The correction of curved tail. 

Instruments. Sharp straight tenotome, bandage. 

Technic. The point or points of curvature and their ex- 
tent are to be carefully noted by having the animal trotted 
away from the operator. The curvature is generally due 
to unequal development of the two levator or extensor 
muscles, Fig. 35, e, though quite rarely the depressors, f y 
may be implicated. 

Confine the animal in stocks, or in default of these, con- 
trol by means of a twitch and sideline. Cleanse and disin- 
fect the tail and have it sharply bent by an assistant in the 
opposite direction to the curvature. Locate the longitudi- 
nal furrow between the levator and depressor muscles on 
what has now become the convex side and at the lower 
margin of the levator and just above v, Fig. 35, insert the 
tenotome at the most prominent part of curvature, the in- 
cision being parallel with the muscle fibers, and push the 
instrument entirely through the muscle to the vertebra, 
then turning the cutting edge upwards, at the same time 
advancing the point toward the median line, sever the en- 
tire muscle. 

The superior lateral caudal artery, s, Fig. 35, bleeds pro- 
fusely if severed, and wounding of it may usually be 
avoided by withdrawing the tenotome a trifle in passing 
that point. 

Wounding the skin over the muscular incision is avoided 
by placing the thumb of the left hand over the line of in- 
cision so the knife will be recognized as soon as the muscle 
and caudal fascia are cut through. Remove the knife in the 
same manner as introduced. Release the horse and have 
him trotted again. //" the operation is sufficient, the tail 
should curve in about the same degree as before, but in the 



SUBCUTANEOUS CAUDAL MYOTOMY 



opposite direction. If this has not been attained, examine 
carefully and sever any remaining bundles of muscle, and 
this not sufficing, repeat the operation as before at another 
point 5 or 6 cm. above or below the first, severing the muscle 
again. Or if the depressor appears implicated, sever it in 
a similar manner. In extreme cases the entire lateral half 
of the caudal muscles, tendons and aponeurosis may be 
severed. 




FIG. 35 

Transverse section of the tail. ;/, Caudal vertebra ; c, sacro- 
-coccygeus lateralis muscle ; <?, sacro-coccygeus superior ; f, 
depressor longus and brevis muscles (sacro-coccygeus infer- 
ior ;) i, intertransversales muscles; <?, coccygeal artery ; s, 
supero-lateral coccygeal artery ; /, infero-lateral coccygeal 
artery; z/, caudal veins (dorsal, ventral, lateral) ; sch, caudal 
fascia ; h, skin. 
-Apply an antiseptic pad to the wound and retain it by a 
moderately firm bandage, which serves at once as an occlu- 
sive dressing and effective hemostatic. Remove the band- 
age after 24 hours. By this plan of operation it is^not 
intended to tie the tail to the side of the animal during the 
time of healing but when bandaging immediately after the 
operation, the tail should be held away from the side toward 
which it formerly curved so that the bandage may tend to 
prevent the return of the organ to its former position. 



CAUDAL MYECTOMY 



24. CAUDAL MYECTOMY 
Figs. 35, 36 

Objects. For the prevention of the gripping of the reins 
by the tail. 

Instruments. Elastic ligature, straight bistoury, tenacula, 
absorbent cotton, bandages. 

Technic. Confine the animal in lateral decubitis or in 
stocks, cleanse and disinfect the parts and apply the elastic 
ligature as close as possible to the root of the tail. Have 
an assistant hold the tail upward, i. e., dorsalward, and 
tightly stretched. Make an incision 15 to 20 cm. long, over 
the middle of the inferior surface of each depressor longus 
muscle, beginning close against the elastic ligature and ex- 
tending toward the apex, severing at once the skin and 
caudal fascia down to the muscle. Let an assistant retract 
the lips of the incision with tenacula while the operator 
dissects the depressor longus muscle, DC, Fig. 36, from 
the adjacent tissues at either side, sever it by a transverse 
incision close against the ligature and dissect away the en- 
tire muscle to the distal end of the wound and there excise 
it. Repeat the operation on the opposite side. 

Make two elongated tampons of absorbent cotton, of the 
size and form of the muscles removed, saturate these with 
1- 1000 sublimate solution, insert neatly in the wounds and 
over this, to aid in securing antisepsis and to equalize the 
pressure, apply a pad of absorbent cotton, saturated with 
sublimate solution, covering the wounds and encircling the 
tail and secure by a moderately firm bandage as closely as 
possible to the elastic ligature. Remove the ligature, when 
hemorrhage may ensue, which is to be controlled by the 
application of a second bandage extending higher up on the 
tail. Remove the bandage in 24 hours and dress as before 
for a second day, after which treat as an open wound. Care 




FIG. 36 

Caudal Myectomy To Prevent Gripping of the Reins 

DC, Depressor coccygeus longus muscle ; T, tourniquet. 



AMPUTATION OF THE TAIL 91 

should be taken not to apply the bandage too tightly or 
leave it in place for more than 24 hours, since otherwise 
necrosis of the tail is liable to occur and necessitate 
amputation. 



25. AMPUTATION OF THE TAIL 
Figs. 37, 38 

Objects. The treatment of malignant, or incurable dis- 
eases oi the tail. 

Instruments. Elastic bandage, scalpel, razor, artery for- 
ceps, bone cutting forceps, suture material. 

Technic The animal may generally be operated upon in 
a standing position secured in the stocks or with the aid of 
the side line. Local anaesthesia may be applied by inject- 
ing cocaine or other drug deeply upon the nerve trunks as 
well as just beneath the skin. The animal's attention may 
be attracted by means of the twitch if found necessary. 
The point of amputation is determined by the location of 
the disease. Over the area of operation clip the hair, shave 
and thoroughly disinfect. Apply the tourniquet or elastic 
bandage at the base of the tail so as to render the operation 
bloodless. 

Above the seat of operation turn the hair upward toward 
the root of the tail and secure it there by means of the 
bandage, B, Fig. 37. Locate as accurately as possible the 
position of a joint at the point where it is desired to operate, 
and with the scalpel begin an incision on the median line 
on the upper side of the organ about 1 cm. above the artic- 
ulation and carry this obliquely outward for a distance of 4 
to 6 cm. according to the size of the tail and then continue 
it downward, backward and inward along the side and in- 
ferior surface until directly opposite to the place of begin- 
ning. Make a similar incision upon the opposite side of the 
tail, cut through all the connective tissue and muscles down 




FIG 37. Amputation of the Tail 

Tail amputated showing flaps unsutured ; B, Bandage securing 
hairs turned upward out of operators way. 




FIG. 38. Amputation of the Taill 

Operation completed showing sutures ; B, Bandage applied to 
secure hairs of\.tail upward out of operator's way. 



AMPUTATION OF THE TAIL 93 

to the bone and then disarticulate with the aid of the scal- 
pel. Search for the arteries and control the hemorrhage 
by torsion or ligation. The vessels will be more readily 
found by loosening the tourniquet so as to permit the blood 
to flow. 

Some operators prefer to begin the incision at the side of 
the tail instead of upon the dorsal surface and in that way 
have a dorsal and ventral flap instead of right and left as 
indicated in Fig. 37. The excision having been completed, 
the flaps are brought together by means of strong silk or 
silk worm gut sutures as shown in Fig. 38. The sutures 
should be begun at the apex of the two flaps and compara- 
tively deep. 

Disinfect the stump thoroughly and if the hair is suffi- 
ciently long it is well to draw it down over the wound, to 
which an antiseptic covering has been applied, and retain 
the dressing in position by tying a cord around the hair just 
beyond the point of amputation. 



26. URETHROTOMY. LITHOTOMY. 
Figs. 39, 40. 

Objects. For the removal of calculi from the bladder or 
urethra or performing other operations on these parts. 

Instruments. Catheter, convex scalpel, scissors, artery 
and compression forceps, tenacula, lithotome, lithotomy 
forceps, lithotrite, absorbent cotton, drainage tube, suture 
material. 

Technic. Urethrotomy may be performed on horses in 
the standing position, the hind feet being secured with 
hobbles. 

It is best however, to operate under anaesthesia with the 
patient in lateral or dorsal recumbency, either on the 
operating table or cast, being careful to secure as gently as 



94 



URETHROTOMY. LITHOTOMY 



possible, having first emptied the bladder if practicable, 
since rupture of an over distended viscus may readily oc- 
cur during violent struggles by the animal. 

The point of operation will depend upon the location of 
the calculus or other obstacle. If it is found in the pelvic 
portion of the urethra or in the bladder, the operation is 
made at the ischial notch, Fig. 39. First the penis is drawn 
out from the prepuce and the catheter introduced into the 




FIG. 39 

Urethrotomy at the ischial notch, 
urethra and pushed upward until it has passed the ischial 
notch. After disinfection of the skin, render it tense and 
make a 5 cm. long incision on the median line at the ischial 
arch through the skin, bulbo-cavernosus muscle, spongy 
portion of the urethra, and the urethral mucous membrane 
down to the catheter, Fig. 40, k. In order to prevent infiltra- 
tion of urine after the operation, special care is to be taken 
to make the lower end of the wound slanting in such a 
manner that the deeper margin is higher than the super- 
ficial. 



URETHROTOMY. LITHOTOMY 



95 



After the catheter has been drawn back away from the 
ischial arch, introduce the lithotomy forceps into the urethra 
or bladder, grasp the stone and draw it outward in its natural 
direction. The grasping of the stone with the forceps is 
materially aided by means of the left hand introduced into 
the rectum. One must avoid grasping, along with the 
stone, the mucous membrane of the bladder. Partial filling 




Urethrotomy (life size), h, Skin ; a, retractor penis muscle ; 
b, bulbo-cavernosus muscle ; c, spongy urethra ; u, urethra ; 
k, catheter. 

of the bladder with a tepid aseptic solution will aid in grasp- 
ing the calculus and in avoiding the implication of the 
bladder walls. By careful rotary movement and pushing 
the forceps backward and forward, the operator can deter- 
mine before traction is exerted if the forceps can be with- 
drawn easily and without much resistance through the neck 
of the bladder. 

If the stone is so large that it cannot pass the neck of the 
bladder, lithotripsy may be performed. This operation re- 



96 URETHROTOMY. LITHOTOMY 

quires time and patience, since as a rule it is not possible to 
encompass the entire calculus with the forceps. That is, 
the narrowness of the neck of the bladder prevents the 
sufficiently wide opening of the forceps. The stone con- 
sequently must be gradually broken off at its periphery and 
the individual pieces of calculus removed. The character 
of the surface of the stone has an evident bearing upon the 
practicability of lithotripsy. 

The surgical dilation of the pelvic urethra with the 
lithotome is usually far more practical than the crushing of 
the stone. Introduce the instrument and divide the urethra 
upward on the median line as the instrument is withdrawn. 
In order to prevent injury to the rectum, it should be 
emptied of feces before the operation is undertaken. After 
the removal of the stone, the operator may push the catheter 
again over the ischial arch and unite the lips of the wound 
in the urethral mucous membrane by means of intestinal 
sutures. Flush the bladder and urethra by means of a 
warm, 3 per cent, boric acid solution injected through the 
catheter and then withdraw the latter. Finally, suture the 
skin wound and insert a drainage tube or antiseptic gauze 
in the lower angle. 

Or the whole wound may be left entirely open and dressed 
daily with antiseptics. In case the pelvic urethra has been 
divided, the suturing of the external wound is of question- 
able utility. 

(For student practice on an anaesthetized horse, intro- 
duce a stone into the bladder through the urethral wound 
and practice grasping and removing it with the lithotomy 
forceps. ) 

27. AMPUTATION OF THE PENIS 
Figs. 41, 42, 43 

Instruments. Scalpel, elastic ligature, strong silk suture, 
strong piece of tape 1 m. long, artery and compression 
foi ceps. 




IV-L 



FIG. 41. Amputation of Penis 

First stage of operation. T, Elastic ligature used as tourniquet ; 
CS, Corpus spongiosum of urethra ; S, Skin ; CC, Corpus caver- 
nosum ; U, Urethra ; L, Ligature ; C, Catheter. 




HG. 42. Amputation of the Penis. 

Completed operation showing sutures. U, Urethra 



AMPUTATION OF THE PENIS 



99 



Technic. The operation is carried out on the recumbent 
animal under local or general anaesthesia, the upper hind 
foot being drawn backward or upward or otherwise so fixed 
as not to obstruct the field of operation. The point of 
operation is determined by the character of the disease and 
the object to be attained. It may be made at any point 




FIG. 43. 

Amputation of the penis, showing needle inserted for a suture. 
V, Dorsal vessels of penis ; A, fibrous tunic of the corpus 
cavernosum ; S, skin ; CC, corpus cavernosum ; CS, corpus 
spongiosum of urethra ; U, urethra. 

from the glans penis to the attachment of the corpus caver- 
nosum to the ischium. If possible, amputate in front of the 
preputial ring. 



100 AMPUTATION OF THE PENIS 

After the penis has been drawn out, and the preputial 
region carefully cleansed and disinfected, an assistant grasps 
the organ just behind the preputial ring and holds it firmly, 
A catheter is then introduced into the urethra and pushed 
upwards beyond the point where it is designed to amputate 
the organ and a temporary elastic ligature, T, is then ap- 
plied above the assistant's hand around the penis, or a piece 
of tape is looped around it above the hand and is made to 
serve both as a tourniquet and as a means for holding the 
penis. Or the penis may be grasped in front of the liga- 
ture with double tenaculum forceps and held. 

Apply a small cord just behind the glans penis, L., Fig. 
41, and then make a triangular incision on the ventral sur- 
face of the organ about 4 cm. long by 3 cm. wide, the base 
of the triangle being forward as shown in the figure ; carry 
this incision through the skin, S, the corpus spongiosum, 
CS, and along the corpus cavernosum, CC, down to the 
urethra, U. Dissect away the tissues in the triangular 
area without opening or wounding the urethra and when 
this lias been completed make a longitudinal incision from 
near the apex of the triangle to its base through the urethral 
walls to the catheter. Beginning at the apex of the trian- 
gular wound, insert a series of interrupted sutures as shown 
in Fig. 42, in such a manner that they pass through the 
urethral wall and the skin so that when tied the wounded 
surfaces are completely hidden and the urethral mucous 
membrane is brought into apposition with the integument. 
Continue these sutures down to the base of the triangle, 
after which remove the catherer and excise the organ by a 
cut extending in a slightly oblique direction from below 
upward and forward. Take a straight needle armed with 
a silk suture and passing it through the margin of the 
urethral wound, the adjacent fibrous capsule of the corpus 
cavernosum and across but not through the erectile tissue, 
insert it again into the superior portion of the fibrous cap- 



AMPUTATION OF THE PENIS 101 

sule and carry it out through the adjacent dorsal vessels 
and the skin as shown in Fig 43, and, bringing the ends of 
the sutures together, tie in such - a way that the urethral 
mucous membrane and the margin of the skin are brought 
into immediate contact and the blood vessels securely 
closed in such a manner as to guard against hemorrhage. 
By this plan when the sutures are tied, the cut borders of 
the fibrous envelope are brought together over the erectile 
tissue, thus preventing hemorrhage from that tissue also. 
Insert as many sutures as may be required to completely 
and securely close the wound, and finally leave every part 
wholly covered with epithelium. By this plan stricture of 
the urethra in the process of healing is avoided. Remove 
the tourniquet and release the patient. 

The principles here laid down are applicable and advisa- 
ble in the amputation of the penis in all domestic animals. 
In the dog, the point of amputation should be above the 
penial bone. 



28. VAGINAL OVARIOTOMY IN THE MARE 
Figs. 44, 45. 

Objects. The alleviation of vice when related to ovarian 
irritation or disease. 

Instruments. Colin's scalpel, ratchet ecraseur, 55 cm. 
long, vaginal tensor. 

Preparation of patient. It is best to keep the animal on a 
scant laxative diet for at least 24 hours and preferably 
longer, prior to the operation, so that the alimentary canal 
shall be somewhat empty and thus decrease the intra-ab- 
dominal tension and relieve the operator from much annoy- 
ance due to the pressure of the viscera. Before commenc- 
ing the operation, it is best to have an assistant empty the 
rectum manually. Do not use enema because there is dan- 



102 



VAGINAL OVARIOTOMY IN THE MARE 



ger from the expulsion of liquid feces during the operation. 
It is best, also, to empty the bladder before operating, other- 
wise the animal is quite sure to urinate during the opera- 
tion. 

Technic. The introduction of the hand into the vagina of 
the mare causes the admission of air along the side of the 
hand and arm. The vulvar lips fail to envelop the hand 
and arm closely and the irritation or shock causes the animal 
to draw air into the vagina alongside the arm, and fully 
balloon it. The movements of the diaphragm in respiration 
tend to cause a vacuum of both chest and abdomen during 




FIG. 44. 

Special spa)-ing ecraseur, 55 cm. long. 




FIG. 45. 

Colin's scalpel. 

inspiration, and if the vulva is partly propped open and the 
abdominal walls are fixed, air rushes in. The vagina may 
also be distended by filling it with warm water. Under 
these conditions the vaginal walls become hard, and stand 
apart from each other, closely applied against the pelvic 
walls at every part except that at the points where the 
bladder and rectum intervene, and these organs are pressed 
out flat and occupy a minimum amount of space. In the 



VAGINAL OVARIOTOMY IN THE MARE 103 

quiescent state the vaginal walls are in contact. From the 
perinaeum forward to within about 10 cm. of the uterine 
os, the vulva and vagina are connected above with the 
rectum by the pelvic connective tissue, while anterior to 
this point the vagina is covered by peritoneum. It is in 
this area that the incision needs to be made in the opera- 
tion. The ballooning of the vagina profoundly alters the 
relation of this operative area, and changes it from the 
horizontal in the quiescent organ to the perpendicular in 
the ballooned condition. These variations permit of two 
methods of operating : I. On the ballooned organ without 
anaesthesia and with the animal confined . in the standing 
position. II. On the quiescent organ in the recumbent 
position under anaesthesia : 

I. Without anaesthesia. Secure in the stocks with the 
head elevated, a rope over the back to prevent rearing, 
straps beneath the body to prevent lying down, straps or 
ropes before and behind the animal to prevent backward 
and forward movements, all four feet pinioned to the floor, 
and the tail firmly secured and stretched to a beam above. 
Apply a bandage to the tail extending for a distance of 12 
to 15 inches from its base in order to secure the tail hairs 
out of the way of the operator. 

With soap, water and brush cleanse the tail, perineum and 
vulva thoroughly, being especially careful to remove all 
detachable masses of sebum ; 50 per cent, alchohol or gaso- 
line may be used sparingly to aid in removing this. Too 
free a use of alcohol excoriates the delicate skin. Cleanse 
the clitoris carefully. Follow the washing with a free ap- 
plication of 1:1000 aqueous sublimate solution to the ex- 
ternal parts and for a short distance inside the vulvar lips 
and to the clitoris. Do not introduce irritant disinfectants 
into the healthy vagina nor deeply into the vulva as it may 
cause severe straining during and subsequent to the opera- 
tion and by injuring the vulvo-vaginal mucosa favor subse- 



104 VAGINAL OVARIOTOMY IN THE MARE 

quent infection of the vaginal wound. The vagina may 
with benefit be flushed out mechanically with 0.6% salt or 
soda solution. 

Wash away the sublimate solution with a tepid 0.6 per 
cent soda bicarbonate solution, and fill the vulvo-vaginal 
canal with the same. After thorough disinfection of the 
hands and arms, remove the disinfectants by washing in 
sterile soda solution, which at the same time renders the 
hand unctuous and readily introduced through the vulva. 
Armed with the guarded sterilized scalpel, Fig. 45, intro- 
duce the right hand into the vagina promptly and when it 
is well "ballooned," unsheath the knife. Place it just 
above the os uteri parallel to the long axis of the uterus, 
a few mm. to the right or left of the median line in order to 
avoid a loose fold of mucous membrane generally existing 
there. Hold the blade vertical, that is, with the cutting 
surface parallel to the longitudinal muscular fibers of the 
vagina, and guarding the possible extent of its introduction 
with the thumb and fingers, push it directly forward in a 
straight line with a quick thrust through vaginal mucosa, 
the muscular walls and the peritoneum, until the disap- 
pearance of resistance indicates that the latter has been 
penetrated. This is the most critical step in the operation. 

If the hand is introduced into the vagina immediately 
after the injection of the sterile saline solution, the vagina 
will generally be found " ballooned " or will quickly become 
inflated under manual movements. If the solution is thrown 
out, the vagina may collapse and closely invest the hand, in, 
which case more of the liquid should be injected when it 
will again dilate. If the hand is introduced without the 
knife, withdrawn, and then introduced with it, it will be 
frequently found that the vagina has collapsed and needs a 
second filling with the fluid. Patience until dilation is 
accomplished and promptness to act when attained are prime 
requisites to success. 



VAGINAL OVARIOTOMY IN THE MARE 105 

The knife should be pushed through the vagina quickly, 
making a clean wound the width of the blade, when the 
latter is to be withdrawn and laid aside. It should be re- 
membered that in this "ballooned'' state, the anterior wall 
of the vagina is but 2 or 3 mm. thick and easily penetrated. 
Introduce the hand again, push one ringer into the incis- 
ion, then a second and third, and eventually holding all 
the fingers in the form of a cone, push the entire hand into 
the peritoneal cavity. Immediately below the incision and 
continuous with the tissues involved in the wound, lies the 
uterus with a transverse diameter of 4 to 6 cm. With the 
palm of the hand downward, trace the uterus forward a dis- 
tance of 15 to 18 cm., where it ends abruptly in two cornua 
of about the same size as the body, which are given off 
horizontally at almost right angles. Trace these to the 
right and left for a distance of 14 or 15 cm., where they end 
obtusely, and 3 or 4 cm. beyond this in a direct line, resting 
upon the anterior border of the broad ligament is the dense 
oval ovary varying in size from 2.5 to 7 cm. in diameter. 

Prepare the ecraseur for use by withdrawing the chain 
until the loop is of barely sufficient size to admit of its being 
readih 7 slipped over the ovary. Grasp this loop and the 
end of the ecraseur tube in the hand, carry the instrument 
to the ovary and drop the loop over it from above. Pass 
some of the fingers beneath the ovary and push it up 
through the chain loop and grasp it there with the thumb 
and index finger. Holding the ovary with one hand, tighten 
the chain quickly with the other, examine to make sure 
that a loop of intestine is not caught, draw the ovary well 
through and get a large portion of the oviduct, and crush 
off promptly, holding to the gland until carried out through 
the vulva. Remove the other ovary in the same way. 
Generally it is most convenient to remove the left ovary 
with the right hand and vice- versa, but each may be re- 
moved with either hand. Wash away any blood from the 



106 VAGINAL OVARIOTOMY IN THE MARE 

external parts, apply sublimate solution freely to the vulva, 
perineum and tail. Keep the patient quiet for five or six 
days, and feed lightly on a laxative diet. 

II. In operating under anaesthesia, the animal should be 
cast or confined upon the operating table in lateral recum- 
bency preferably with the posterior part of the body some- 
what higher than the anterior in order to avoid visceral 
pressure in the pelvic cavity.' Place the animal under com- 
plete anaethesia. Prepare the parts in the same manner as 
already described. Carry the knife into the vagina in the 
manner previously described and render the roof of that 
organ tense by pushing the os uteri downward and forward 
with the hand or by means of a vaginal tensor or speculum. 
It is important that the vagina be held well down toward 
the floor of the pelvis, so as to carry it away from the rec- 
tum, posterior aorta and iliac arteries while the incision is 
being made. The incision is now to be made just above and 
behind and a trifle to one side of the os uteri in essentially 
the same manner as under I, except that when the vaginal 
tensor is used, the cut is made upward and backward instead 
of directly forward. The remainder of the operation is 
identical with what we have described under I. Under 
anaesthesia the vagina is flaccid and cannot be made to- 
''balloon " but may be distended with sterile soda or salt 
solution. 

Dangers. Wounding of the rectum is scarcely possible un- 
der the first method if it has been emptied as advised on page 
101 and care is taken not to attempt the incision until the va- 
gina is well il ballooned," and then making the stab wound 
directly forward. If made upward when the organ is so 
tensed, the accident is highly probable, and with the undi- 
lated vagina, where it is necessary to cut upward, the dan- 
ger is ever present. Its prevention demands that in the first 
method, the operator await the complete "ballooning" 
and then make his incision as directed. In the second 



VAGINAL OVARIOTOMY IN THE MARE 107 

method, the accident is to be prevented by being careful to 
push the vagina down away from the rectum and hold it 
away while the incision is being made. If the wound in the 
rectum passes through the pelvic connective tissue behind 
the peritoneum, it is of little consequence, but the opera- 
tion should be abandoned ; if the bowel is opened into the 
peritoneal cavity, the accident is generally fatal. The acci- 
dent is not necessarily fatal. The vaginal incision may be 
enlarged and the wounded portion of the rectum drawn out 
through the vulva. The wound may then be closed by 
sutures. 

Wounding Of the iliac arteries, which generally produces 
prompt death from hemorrhage, results from the incision 
being made upward instead of forward when the vagina is 
''ballooned" or from a failure to hold the roof of the 
vagina down and away from the part while makiug the in- 
cision in the flaccid organ as is the case with the recumbent 
animal under anaesthesia, It is most likely to occur with 
timid operators who become nervous, especially when the 
vagina does not "balloon" promptly or the mare is not 
well secured. The accident is wholly unnecessary if the 
operator will await the "ballooning" in the first operation, 
while by the second method it is prevented by proper care 
in holding the vagina downward and forward during the 
incision. When it has occurred, it is generally beyond 
remedy though in some cases the prompt intravenous injec- 
tion of adrenalin chloride may stay the hemorrhage and 
save the life of the patient. 

Wounding of the Uterus may occur when the incision is 
directed downward and may greatly embarrass the operator 
and confuse him because his fingers or hand may pass 
through the incision into the uterine cavity. It is to be 
avoided in the first operation (without anaesthesia) by care- 
fully directing the incision straight forward. When the 
accident occurs it is of little consequence beyond the em- 



108 VAGINAL OVARIOTOMY IN THE MARE 

barrassment and may be overcome by again dilating the 
vagina with fresh injections of the soda solution and making 
a new incision, or if preferred, the first cut may be corrected 
by placing an index finger against the peritoneum at the 
upper part of the wound, and with a sudden and vigorous 
thrust, breaking through into the peritoneal cavity, or the 
error may be corrected by again using the scalpel and direct- 
ing the incision properly. If it is attempted to rupture the 
peritoneum with the finger, it must be done by a sharp thrust 
since otherwise a large section of the membrane will be 
pushed away from the subjacent tissues. 

Incomplete penetration of the vaginal wall is liable to occur 

if the scalpel is dull or the vagina imperfectly " ballooned " 
and flaccid, or the operator is unduly timid. It is best pre- 
vented by avoiding the causes as related, and once it has 
occurred, it is generally best to again " balloon " the organ 
in the operation without anaesthesia and make a new in- 
cision either to the right or left of the first. It may be 
overcome also by thrusting the index finger through the 
peritoneum as described in the preceding paragraph or 
by completing the cut with the scalpel. 

The mistaking of a ball of feces for the ovary has occurred 
to inexperienced operators and the fatal error of removing 
the portion of the rectum surrounding the fecal pellet com- 
mitted. The blunder is uncalled for; the fecal ball is 
movable in the bowel, the intestine is far more massive 
than the broad ligament, and the ovary is to be definitely 
identified by its being lodged in the broad ligament just 
beyond the end of the cornua, which is continuous with the 
uterus. If, therefore, one traces the uterus forward to the 
cornua, thence along each of these to their extremeties and 
along the borders of the broad ligament to the ovary, as 
above directed, the error will not occur. 

The vaginal incision may be made too low and pass beneath 
the broad ligament. It is to be avoided by being careful to 



VAGINAL OVARIOTOMY IN THE COW 109 

keep close to the median line and above the cs uteri. If it 
occurs, the operation may be completed from beneath with- 
out very great difficulty, only that the ovary now lies above 
the hand and must be drawn down from on top the broad 
ligament in order to fix the ecraseur upon it. 

Infection always constitutes the most serious danger and 
is to be avoided by properly securing the animal, by the 
avoidance of irritant antiseptics in the vagina, by rigid 
asepsis at every stage, and by carrying out the mechanical 
parts of the operation deliberately, vigorously and neatly. 
If infection should occur, it will generally take the form of 
pelvic cellulitis with abscesses and rectal stricture. Enemas 
of normal salt or soda solution afford the surest relief of 
the stricture and impaction in front of it. The abscesses 
must be watched and opened early into the vagina or rec- 
tum, and the case treated internally and locally according 
to general surgical principles. 



30. VAGINAL OVARIOTOMY IN THE COW 

Objects. Vaginal ovariotomy has been alleged to increase 
the yield of milk and butter fat, but the evidence is not 
good. It serves a useful purpose in cases of nymphomania 
and other ovarian disease. In some cases of sterility, disease 
of one ovary may inhibit ovulation by the healthy ovary 
and the removal of the diseased gland may be advisable in 
order to permit the healthy gland to function. 

Instruments. Colin's scalpel, vaginal dilator, spaying 
ecraseur, or emasculator. 

Technic. Confine the cow in the standing position in the 
stocks, secure the head firmly and pass two boards beneath 
the abdomen and sternum to prevent lying down, and a 
rope over the middle of the back to prevent arching of the 
spinal column and straining. 



110 VAGINAL OVARIOTOMY IN THE COW 

Wash and disinfect the tail and the perineum and flush 
out the vagina with a 0.5 % solution of carbolic acid 
or lysol at a temperature of about ioo° F. Insert the 
vaginal dilator with one hand and push the prolongation at 
the anterior end into the os uteri. With the other hand, 
elevate the handle of the dilator and depress and push for- 
ward the uterus, thus rendering the roof of the vagina 
tense and pushing it downward away from the rectum. 
Carry the scalpel into the vagina with the right hand and 
resting it in the oval of the dilator, make an incision through 
the roof of the vagina, beginning at a point 8 to 10 cm. 
posterior to the os uteri and extending backward on the 
median line for a distance of 2 or 3 cm. Be careful to 
make the incision entirely through the mucosa, muscle and 
peritoneum at the first cut, since any failure to complete it 
tends to cause the peritoneum to separate from the muscu- 
lar coat and form a pocket between them, while the serous 
membrane being very elastic, renders it difficult to complete 
the incision. Introduce two fingers through the incision, 
and reaching over the side of the vagina to the right or 
the left, the right or left ovary respectively is recognized 
lying immediately against the lower part of the base of the 
uterine horn, just at the anterior border of the pubis, in a 
mass consisting of the cord-like Fallopian tube and the fim- 
briae of its pavilion. The ovary may be distinguished as a 
firm oval mass 2 to 4 cm. in length and 1 to 2 cm. in its 
lesser diameter attached to the broad ligament. If not 
promptly recognized by the sense of touch, trace the vagina 
and uterus forward with the fingers from the vaginal in- 
cision to the cornua and follow them as they bend forward 
and downward, and then backward and upward to the ovi- 
ducts, until the ovary is reached where it is attached to the 
broad ligament, just beyond the fimbriated end. 

Grasp the ovary between the fingers and draw it through 
the incision into the vagina. Introduce the emasculator 



VAGINAL OVARIOTOMY IN THE COW 111 

with the other hand, and when the ovary is reached, open 
the instrument far enough to admit the ovarian attach- 
ments between the jaws, push the ligament between the 
jaws, close the forceps and sever the ovary. Or introduce 
the ecraseur, draw the ovary through the loop of the chain 
and holding it securely until the instrument is tightened, 
crush it off. 

It is essential that plenty of the broad ligament and ovi- 
duct be excised with the ovary to insure the entire removal 
of the gland, because the accidental leaving of the smallest 
particle of ovarian tissue may cause a development of this 
into abnormally large cystic ovisacs, and will tend to in- 
crease, instead of decrease nymphomania. Should the ani- 
mal be pregnant, the ovary on the gravid side is dragged 
downward and forward out of reach of the operator's fin- 
gers, and if it is desired to complete the operation, it may be 
necessary to enlarge the vaginal wound and introduce the 
entire hand, when the ovary can be reached and removed. 
Generally no after care is necessary. 

The Dangers are similar to those of the mare. The iliac arter- 
ies may be wounded in the same manner as in the mare. The 
accident is preventable by being careful to push the vaginal 
roof well downward away from the rectum and sacrum. In 
rare instances fatal hemorrhage occurs from the severed 
ovarian arteries, especially in badly diseased ovaries accom- 
panied by a want of tone. For this reason it is safer in 
cows sterile from diseased ovaries to use the ecraseur but 
even this instrument is not wholly proof against fatal hem- 
orrhage, consequently some veterinarians have advised liga- 
tion of the arteries. This is especially necessary in highly 
vascular diseased ovaries. The gland is then to be cau- 
tiously drawn into the vagina and a silk ligature in the 
form of a running noose with two long ends, applied. Af- 
ter the noose has been tightened, a second tie may be begun 
outside the vulva and the knot tied by following one of the 



112 OVARIOTOMY IN THE COW BY THE FLANK 

threads into the vagina with the hand. Another danger 
appears in the presence of the rumen, the supero-posterior 
portion of which when filled with food projects into the 
pelvic cavity and if the cut is directed forward, a stab 
wound readily penetrates its walls with fatal results. Make 
the cut upward and backward. 



31. OVARIOTOMY IN THE COW BY THE FLANK 

Instruments. Clipping shears, convex scalpel, spaying 
emasculator, or ecraseur, heavy needle and thread. 

Uses. Same as the preceding, applicable to heifers or to* 
cows in which the vulva is too small to admit the operator's 
hand or in case of diseased vagina or uterus. 

The animal may be secured as in the preceding or con- 
fined in lateral recumbency with the hind legs extended 
backward and the anterior limbs forward. To accomplish 
this, loop a rope about the two fore feet, another about the 
two hind feet, and drawing upon these, cast the animal and 
secure it in recumbency with the legs extended and body 
stretched by fastening the ropes to two strong posts about 
8 to io m. apart. The operation may be performed in either 
flank. 

Clip the hair from the upper part of the flank, disinfect 
an area 15 to 25 cm. square and make an incision about 12 
cm. long beginning at a point equidistant from the anterior 
tuberosity of the ilium, the ends of the transverse processes 
of the lumbar vertebrae and the last rib, and extend it down- 
ward perpendicularly, severing the skin and subcutaneous 
muscle. Divide the external oblique muscle in the direc- 
tion of its fibres by means of the scalpel handle or the fingers 
and repeat the process upon the internal oblique, after which 
puncture the peritoneum with the scalpel. When ope- 
rating upon large numbers of animals, and greater rapidity 
is desired, the entire abdominal wall is cut directly through 
at a single stroke. 



OVARIOTOMY IN THE BITCH 113 

Force one hand through the opening into the peritoneal 
cavity and search for the ovaries at the same point and by 
the same method as in the preceding operation, that is, 
locate the uterus within the pelvic cavity, between the rec- 
tum and bladder and trace it, the cornu, and broad ligament 
to the ovary. The uppermost ovary can be drawn out 
through the wound and cut off ; the lower one must be held 
with one hand, the instrument introduced along the arm 
and when the ovary is reached, apply the emasculator or 
ecraseur to the ovarian attachments and closing the instru- 
ment cut or crush off the gland. The beginner must al- 
ways remember that the positive means for identifying the 
ovary is by tracing the uterus from the vagina along the 
cornu to the oviduct and thence to the organ in the broad 
ligament. Cleanse the wound and close the skin incision 
with continuous sutures. 



3 2. OVARIOTOMY IN THE BITCH BY THE FLANK 
Fig. 46 

Instruments. Spaying knife, canine emasculator, scis- 
sors, 3 or 4 pairs of artery forceps, suture material. 

Technic. Confine the animal in lateral recumbency, pre- 
ferably upon the right side for a right-handed operator, the 
head somewhat depressed, the limbs extended and the body 
well stretched. Clip, shave and disinfect a sufficient area 
in the exposed flank at a point just anterior to and beneath 
the external angle of the ilium. Before cutting through 
the abdominal wall, the urinary bladder should be emptied 
if distended. With one hand grasp the skin fold of the 
flank and render the skin of the region tense, while with 
the other, holding the spaying knife like a pen, make at first 
a drawing incision from below upward about 2 to 3 cm. 
long, ending above at a point slightly below the external 
angle of the ilium, the incision extending through the skin 



114 OVARIOTOMY IN THE BITCH 

and subcutaneous tissues ; without removing the knife 
from the wound, elevate the handle and with a quick thrust 
make a stab wound extending through the external and in- 
ternal oblique muscles and peritoneum at a single cut. The 
operator can determine when the peritoneal cavity has been 
entered by the disappearance of resistance. 

Introduce an index finger into the peritoneal cavity, and 
as soon as this has been entered, follow directly along the 
peritoneum upward and backward toward the angle of the 
ilium where the uterine cornua lie covered over by the 
broad ligament. The internal generative organs of the 
bitch are unique among domestic animals. The uterus, 
U, Fig. 46, is small and physiologically unimport- 
ant, the cornua, RUC and LUC, are ample in size and con- 
stitute physiologically the uterus. The distance from the 
cornual extremity, LUC, to the ovary, O, which is occu- 
pied by the Fallopian tube, is very brief so that the cornu 
and ovary are well nigh in contact. The ovary, O, O, is 
very small, smooth and complete^* hidden in the pavilion 
which here constitutes a sac having a very small longitudi- 
nal opening of 2 to 5 mm. The most remarkable feature of 
the apparatus from a surgical standpoint is the great de- 
velopment of the broad ligament which is broader than the 
distance from the lumbar region to the abdominal floor, 
while the uterus and uterine cornua are stretched between 
the vagina, V, and the ovary, O, so that they are suspended 
in the sub-lumbar region, resulting in a double fold of the 
broad ligament hanging down like a curtain between the 
parietal peritoneum and the uterus and cornua on either 
side. The broad ligament of the bitch is consequently sus- 
pended at one end from the sub-lumbar region, at the 
other from the uterus, so that, instead of being sus- 
pended by the ligament, the relation is reversed and the 
ligament is suspended from the uterus, or rather uterine 
cornu. 



OVARIOTOMY IN THE BITCH 115 

In Fig. 46, the right broad ligament, BL', is laid out upon 
the side exposing the right uterine cornu, RUC, while on 
the left side the ligament is divided at about its center and 
the posterior portion, BL', is laid out on the flank, while 
the anterior, BL,, is left in its normal position concealing a 
portion of the cornu, LUC. Unlike other domesticated 
animals, the broad ligament is heavily loaded with fat which 
gives it an appearance very similar to the omentum, but the 
net-work is far less conspicuous or wanting. The omentum 
extends back into this region and is in contact with the 
uterine ligament. 

The ovary is indistinct and hidden which renders it diffi- 
cult to identify directly, and the cornu being covered over 
by the duplication of the broad ligament, is not readily 
reached, so that the finger generally comes in contact first 
with the broad ligament of the uppermost cornu hanging 
loose in the peritoneal cavity ; engage this between the end 
of the finger and the abdominal wall and draw it out through 
the wound, grasp it and continue drawing upon the folds of 
the ligament, especially upon the median or undermost 
portion until the naked cornu appears through the opening, 
seize it and draw out the anterior portion until the ovary 
follows, then grasp the latter with the thumb and index 
finger of one hand and the ovarian ligament with the same 
members of the other and tear the ligament through be- 
tween them by linear tension. Extend the tear through 
the broad ligament as high toward its lumbar attachment 
as is convenient and backward to the neighborhood of the 
uterine bifurcation. Draw upon the exposed cornu until 
the point of bifurcation appears, when the other cornu is 
to be grasped and drawn out through the opening. In 
young puppies the securing of the second cornu is very 
difficult and requires great care to prevent the rupture of 
the first. The object may be facilitated by pressing the 
upper flank of the bitch downward, therein- greatly dimin- 
ishing the transverse diameter of the abdomen. 




FIG. 46 

Ovariotomy in the Bitch 

Abdomen 01 a non-pregnant bitch lying on the back with the abdominal floor removed and 
the omentum pushed away. TT, The two posterior teats; B, bladder; V, vagina; U, 
uterus; LUC, LUC, left uterine corn u with a portion of its broad ligament, BL, lying 
across it; RUC, right uterine cornu with its broad ligament, BL', turned outwards exposing 
the full length of the cornu. On the left side the ligament is divided so that the anterior 
half rests in its normal position while the posterior half, BL', is turned back. O, O, ovaries; 
R, rectum; K, left kidney; A A, a line indicating the level of the external tuberosities of the 



OVARIOTOMY IN THE BITCH 117 

The succeeding operation avoids this difficulty in a large 
measure. Should the distal cornu be ruptured and with its 
ovary drop away from the operator, it becomes necessary to 
turn the animal over and make a second incision on the op- 
posite side, somewhat farther forward. When the second 
cornu has been secured, draw it out as far as practicable 
and holding it tense, insert an index finger along it until the 
ovary is reached. This is recognized by its slightly greater 
size and density succeeding the brief neck representing the 
Fallopian tube between the end of the cornu and ovary. 
Beyond the ovary can be felt the ovarian ligament. Engage 
the ligament between the end of the index finger and the 
abdominal wall, and with a firm and vigorous movement, 
using the finger end and nail as a curette, rupture the 
ovarian ligament by drawing the finger toward the incision, 
and with the aid of tension upon the cornu, draw the ovary 
out through the abdominal incision and divide the broad 
ligament as before. Remove the cornua with the attached 
ovaries by rupturing them transversely near the bifurcation 
by means of linear tension. 

If the bitch be pregnant, and especially if far advanced, 
the uterine cornua will lie upon the abdominal floor, much 
enlarged and very much more flaccid than the non-gravid 
uterus and feeling like intestines. The change in the 
position of the uterus has caused the unfolding of the 
duplicature of the broad ligament so that it no longer covers 
the cornu. In such cases the operation is performed in the 
same way except that rupturing the blood vessels by linear 
tension does not insure against hemorrhage and it is neces- 
sary to ligate the ovarian and uterine arteries with catgut 
or silk. Or the ovary may be removed with the bitch 
emasculator. In cases of pregnancy, the entire cornua 
should be drawn out and a strong ligature placed around 
the uterus or vagina, and the ovaries, uterine cornua and 
their contents be removed en masse. Release the upper 



118 OVARIOTOMY IN THE BITCH 

posterior limb and close the cutaneous wound by a continu- 
ous suture. 

Dangers. Rupture of the uterine cornu alluded to above. 
It is always to be remembered that the leaving of one ovary 
in position even though the other gland with the two cor- 
nua and uterus are removed, induces intense estrum and 
renders the animal if anything more disagreeable than be- 
fore the operation. 

The ureter may rarely be mistaken for the cornu but is 
smaller, is closely attached to the abdominal walls, and 
does not have the broad ligament with its large deposit of 
fat. The kidney is far larger than the ovary, more ex- 
posed, and located more anteriorly. 

The iliac arteries are at times caught and ruptured by 
the finger but the blunder is uncalled for except through 
nervousness of the operator. 

Instances of puncturing the bladder in making the in- 
cision have been reported. If the bitch has been led out 
and caused to urinate prior to operating, the accident is 
made practically impossible. 



33. OVARIOTOMY IN THE BITCH BY THE 
LINEA ALBA 

Instruments. Same as in the preceding. 

Technic. Confine in the dorsal position with the head 
sharply declined. Shave and disinfect an area on the median 
line about 6 cm. square, extending forward from the public 
brim. Make an incision on the median line about 4 cm. 
long beginning just in front of the public brim and extend- 
ing forward, cutting entirely through the skin, the linea 
alba and peritoneum. Insert an index finger and identify 
the uterus or broad ligament by its location and form. 
The finger usually comes in contact first with the urinary 
bladder which may more or less obstruct the passage to the 



OVARIOTOMY IN THE BITCH 119 

uterus according to its degree of distension. When empty 
as shown at B, it offers practically no obstruction. When 
very much distended, it may be evacuated by gentle pressure 
with the fingers. The operator should be careful not to 
draw the bladder out through the incision as its replace- 
ment may prove difficult and its puncture with a hypo- 
dermic needle or an enlargement of the abdominal incision 
may be necessary in order to bring about its return. Push 
the bladder aside if necessary and just above it and below the 
rectum, the uterus should be readily distinguished and either 
it or the broad ligament caught by the finger and brought 
out through the incision, after which the operation proceeds 
in the same manner as by the flank method. By passing 
an index finger forward to reach the lower surface of the 
rectum in front of the uterus and then drawing it back- 
ward, the finger passes between the former and the cornua 
and the latter are picked up. This operation has a distinct 
advantage over the flank method in that in puppies there is 
not so much difficulty in bringing out the ovaries, nor the 
danger of the rupture of the cornu and the ovary's being 
retained. 

By the use of retractors in the abdominal incision, the 
operator is enabled to see every part of the uterus, grasp it 
by means of forceps, and perform all intra-abdominal por- 
tions of the operation with instruments and avoid the ne- 
cessity for introducing the finger into the peritoneal cavity. 

The sutures must extend entirely through the abdominal 
wall and be carefully placed in order to prevent hernia. 
The sutures should be in laminae, the peritoneal of 
catgut, that in the linea alba of slow dissolving cat- 
gut, and those in the skin, of silk or linen. These 
latter may extend down into the linea alba and include 
the wound in that structure in a second suture. 
Interrupted sutures are preferable. If the operation 
has been properly performed, no bandage is ueces- 



120 OVARIOTOMY IN THE CAT 

sary and the patient will not disturb the sutures. If asepsis 
has not been strictly followed, infection may occur and the 
consequent irritation cause the patient to tear the sutures 
out, which may lead to protrusion of the intestines or other 
abdominal viscera. If the sutures do not include the deeper 
layers of the abdominal wall, hernia is liable to occur and 
require a second operation. The silk or linen sutures 
should be removed in seven to ten days. 



34. OVARIOTOMY IN THE CAT 

Instruments. Same as for the bitch. 

Technic. The cat may be spayed either by the flank 
method or through the linea alba. The point of incision in 
either case is the same as in the bitch but owing to the 
smaller size of the animal it is necessary to make the wound 
quite small. The abundance of fur renders it essential that 
an ample area be shaved and the surrounding hair be sat- 
urated with a disinfectant and carefully brushed away 
from the operative area. The cat being more subject to 
infection than the bitch, the aseptic precautions must be of 
the strictest possible character. The operative area must 
be thoroughly disinfected and cleansed and great care must 
be taken not to introduce irritant disinfectants into the 
wound. A great danger also exits in the tendency of the 
muscle layers of the abdomen to readily become separated 
by pressure from the ringer and form a pocket in which 
wound discharges accumulate and constitute a dangerous 
seat for infection. Great care must therefore be taken to 
make a clean incision directly into the peritoneal cavity and 
to avoid separating the peritoneum from the muscles or the 
muscular layers from each other. The uterus and ovaries 
of the cat are naked and far more easily distinguished than 
in the bitch, there being no extra deposit of fat in the broad 
ligament. The sutures are to be applied to the wound in 
the same manner as in the bitch. 



CASTRATION OF CRYPTORCHID HORSES 121 

35. CASTRATION OF CRYPTORCHID HORSES 
Figs. 47, 48 

Instruments. Scalpel, emasculator. 

Technic. Prior to attempting the operation, it is well 
to make a rectal exploration and determine as far as may 
be, the location of the testicle, whether it be on the right 
or left side, and its character, should it be in any way 
pathologic. Confine the animal by casting in the dorsal 
position with the hocks well flexed and both posterior 
limbs completely abducted so as to fully expose the inguinal 
region. Or secure upon the operating table on the side 
opposite to the retained gland and abduct the upper poste- 
rior limb by drawing it upward by means of a pulley. 
Cleanse and disinfect the inguinal region. Anaesthetize. 
Make an incision about io to 12 cm. long through the skin 
and dartos directly over the normal position of the scrotum, 
parallel to the median raphe and about 4 or 5 cm. distant from 
it. Insert the two index fingers in the wound, press them 
into the areolar tissue toward the external inguinal ring 
and drawing them apart, separate the tissues sufficiently to 
permit the entrance of the hand into the inguinal space. 
With the fingers held in the shape of a cone, bore a passage 
in the areolar tissue through the external abdominal ring 
and continue in a direction approximately toward the ex- 
ternal angle of the ilium until the aponeurosis of the small 
oblique muscle near the crural arch is reached. Unless 
rectal exploration has shown that the testicle is within the 
abdomen, take care in traversing the inguinal space between 
the external and internal rings that the gland is not passed 
by unrecognized (inguinal cryptorchidy), lying in this re- 
gion covered by peritoneum and the cremasteric fascia. 
Sometimes the epididymis has descended to the scrotal re- 
gion while the testicle remains within the abdomen, thus 
resulting in a narrow inguinal canal, containing the epi- 
didymis only. 



122 CASTRATION OF CRYPTO RCHID HORSES 

Pass the hand upward, outward and forward along the 
aponeurosis of the small oblique until the crural arch is 
reached, slightly anterior to the crural ring in which the 
pulsating femoral artery can be felt, and palpate at this 
point in the muscular wall for the internal inguinal ring 
which varies greatly in different individuals but usually re- 
veals itself to the fingers as an oblong slit or ring about one 
inch in length covered only by peritoneum. Through this 
usually extends a portion of the gubernaculum testis or of 
the vas deferens. 

Examining Fig. 47, the peritoneal view of the internal 
ring is shown crossed by the dotted line, V, of the upper or 
right testicle, into which the tail of the epididymis extends 
for a short distance. In the lower or left testicle the ring has 
been opened and the gland lies in a position corresponding 
to the right, showing the epididymis and vas deferens 
lying in the processus vaginalis, P. The surgical relation 
of the parts is further illustrated in Fig. 48, where the tes- 
ticle is completely withdrawn into the peritoneal cavity 
and spread out over the right flank. The processus vagi- 
nalis, P, is outlined by a dotted line into which is intro- 
duced a curved sound, S, alongside of which lies the guber- 
naculum, G. The gubernaculum, it will be observed, is 
divisible into three sections, a slender one, G, which by 
passing along behind the peritoneum escapes from the ab- 
dominal cavity at the postero-external commissure of the 
ring to extend to the scrotum. The second portion of this 
organ, G', is much thicker and extends from G to the epi- 
didymis at E, while the third division, G", extends from 
the epididymis to the testicle. 

In Fig. 48, it is shown that the testicle under all ordinary 
conditions is inevitably attached through its gubernaculum 
testis to the postero-external commissure of the ring, 
that it has a second definite attachment to the seminal 
bladder through the medium of the vas deferens, V, and a 



UVx^ 





FIG 47 

Castration of Cryptorchid Horse 

Urino-genital apparatus of 24 hr. colt. T, T, Testicle ; A, testicular 
artery ; G, gubernaculum testis ; V, V, vas deferens ; B, urinary 
bladder ; UA, umbilical arteries retracted within abdomen ; P, pro- 
cessus vaginalis ; UV, umbilical vein. 



124 CASTRATION OF CRYPTORCHID HORSES 

third by means of the testicular artery, A. The guber- 
naculum and the vas deferens constitute the essential guides 
in locating and recognizing the testicle. 

By forming a hollow cone with the fingers about the in- 
ternal ring, the gubernaculum, epididymis, and vas deferens 
tend to drop out into the processus vaginalis where they 
may be grasped with the fingers without having ruptured 
the peritoneum. The vas deferens and epididymis present 
characteristics which are unmistakable to the trained 
touch, consisting of a small firm cord (vas deferens) or a 
small mass of fine threads (tail of epididymis) which roll 
freely between the thumb and finger and give a sensation 
which is unlike that produced by any other tissue in the 
body. 

Grasp the part firmly and tearing through the peritoneum, 
seize the vas deferens and carefully draw it out through 
the external wound. (In teaching cryptorchid castration 
to the beginner, it is best for the instructor to make the 
opening down to the internal ring, grasp the vas deferens 
between the thumb and finger without penetrating the per- 
itioneal cavity and passing a pair of long uterine dressing 
forceps along the hand, fasten them upon the vas deferens. 
The student then completes the operation, using the for- 
ceps as a guide. He thus learns the relations and character 
of the parts and recognizes the internal ring with the peri- 
toneum still stretched across it, intact.) 

In case the vas deferens can not be felt before rupturing the 
peritoneum, that membrane may be broken through with the 
index finger, and inserting the finger into the cavity, the 
gubernaculum is to be found attached to the postero-external 
border of the ring, and but a short distance therefrom the 
finger comes in contact with the vas deferens or with the 
tail of the epididymis where the gubernaculum crosses it at 
E, in Fig. 48. Having reached the vas deferens, the operation 
is proceeded with as above. Thus far the operator has not 



*4 * 1 ^t 

\ ?; .G~ / 





FIG. 48 



Castration of Cryptorchid Horse 

Right inguinal region and testicle of 24 hrs. colt. P, Processus 
vaginalis surrounded by a dotted line and containing a curved sound, 
S ; G, first portion of gubernaculum testis ; G', second portion of gub- 
ernaculum testis extending to the epididymis, E ; E, epididymis ; 
G", gubernaculum extending from epididymis ( globus minor) to the 
testicle ; T, testicle ; A, testicular artery ; V, V. vasa deferentia ; B, 
urinary bladder ; UA, umbilical arteries. 



126 CASTRATION OF CRYPTORCHID HORSES 

concerned himself with the location of the testicle but relies 
wholly upon the vas deferens or gubernaculum, since when 
either of these is recognized, the testicle is virtually within 
his power. 

He thus proceeds upon the basis that he is not to jind the 
testicle for the reason that it is not lost but that it has 
definite relations and attachments which permit of certain 
displacements of the organ itself but not of its attachments. 

Having drawn the vas deferens out through the wound, 
tension is exerted upon it which tends to cause the testicle 
to follow, but sometimes the gland is too large to pass the 
internal ring and the latter needs to be dilated by inserting an 
index finger in it or the testicle needs to be guided through 
the opening. 

We have described herein one method of castrating a 
cryptorchid horse where the cryptorchidy is due to an arrest 
in the development of the gland and of its descent. There 
are other methods employed which introduce variations at 
each step, many operators making the incision over the 
external ring instead of near the median line. Other 
operators avoid opening the internal ring and penetrate the 
peritoneal cavity somewhat in front of and above the ring 
through the small oblique muscle. When one plan has 
been learned, the variations are easily applied. 

There are other causes of cryptorchidy which in rare cases 
require a different procedure in order to extract the gland, 
varying with individual cases, but the essentials for the 
tracing and recognition of the testicle are the same. 

After the testicle is brought to the surface, it may be re- 
moved with the emasculator or by such means as the opera- 
tor may prefer. Cryptorchid testicles when due to arrest 
in development are not vascular and there is little tendency 
to hemorrhage after excision. Place an antiseptic tampon 
in the wound, pushing it well up against the internal ring 



CASTRATION OF CRYPTORCHID BOARS 127 

and retain it in position by means of sutures for a period of 
24 to 48 hours when it is removed and the wound dressed 
antiseptically. 

36. CASTRATION OF CRYPTORCHID BOARS 

Instruments. Razor, convex scalpel, emasculator, artery 
forceps, suture material. 

Purpose. The retention of a testicle by adult boars taints 
the flesh extremely and renders it unfit for human food. 
In some states the law regards as a misdemeanor the sale of 
boar's flesh. The boar must, therefore, be castrated, 
whether normal or cryptorchid, and kept for a considerable 
period thereafter before his flesh becomes fit for food. 

The animal is to be secured in lateral recumbency on the 
normal side, the posterior parts being elevated. The hair 
is clipped or shaved in the upper flank region and the area 
washed and disinfected. A flank incision is then to be 
made as described on page 113 for spaying the bitch. The 
incision should ordinarily suffice for passing two fingers into 
the abdominal cavity. If the operation has been too long 
deferred and the animal is large and fat, the operator, es- 
pecially with short fingers, may be unable to reach suffi- 
ciently into the abdominal cavity, in which case the incision 
needs to be extended to admit the hand. 

With the fingers (or the hand; passed into the peritoneal 
cavity, the testicle is to be located upon the same principles 
as laid down for cryptorchid horses ; the testicle is attached 
to the posterior commissure of the internal inguinal ring by 
the gubernaculum, and to the seminal bladder, just above 
the neck of the urinary bladder, by the vas deferens. The 
gland itself may be anywhere, its size, form, and consistency 
so modified as to be unrecognizable, or the gland may be 
hidden amongst adherent viscera but the gubernaculum and 
vas deferens still constitute the reliable means for identifica- 
tion. 



128 CASTRATION OF CRYPTORCHID BOARS 

The vas deferens, gubernaculum, or epididymis having 
been recognized, it is grasped and, with the testicle follow- 
ing, drawn through the flank incision and detached by 
means of the emasculator or by other hemostatic method. 

If one testicle has been removed and the operator errone- 
ously performs laparatomy on the wrong side, he may reach 
across to the opposite side and complete the operation. If 
both testicles be cryptorchid, and the uppermost gland has 
been removed, the fingers or hand may be passed across the 
floor of the belly to the opposite side and the distal gland 
located, withdrawn and removed through the opening 
already made. 

When the laparotomy incision is made well up in the 
flank, only cutaneous sutures are required. They are made 
of strong linen. 

The technic here described answers for cryptorchidy in 
dogs and cats. Cryptorchidy in ruminants is rarely sub- 
mitted to surgical procedure because the presence of testi- 
cles does not taint the meat and up to sex maturity does 
not interfere with growth. They are, therefore, usually 
slaughtered early. In exceptional cases where surgical in- 
terference is demanded, the technic described for the boar 
suffices. 



IV. OPERATIONS ON THE EXTREMITIES 

37. TENOTOMY OF THE FLEXORS OF THE PHALANGES 

Fig. 49 

Objects. The relief of contraction of the flexor tendons 
of the foot. 

Instruments. Razor, scissors, sharp tenotome, bandage 
material. 

Technic. Tenotomy is generally performed on the flexor 
of the third phalanx, seldom on the superficial flexor or 
flexor of the second phalanx. 

Quiet horses may be operated upon in the standing posi- 
tion with local anaesthesia. Otherwise secure upon the 
operating table with the affected member undermost and 
the foot fully extended, or in default of a table, confine in 
lateral recumbency and apply an extension splint to the foot 
as shown in Fig. 49. 

On the median side at the middle of the metacarpus or 
metatarsus, the skin is shaved and disinfected over the ten- 
don of the flexor pedis muscle. The location named lies 
between the lower extremity of the great carpal or tarsal 
sheath above and the superior extremity of the tendonous 
sheath of the fetlock below, so that neither of these is 
wounded during the operation, but the tendon is severed at 
a point where it is invested by loose connective tissue which 
retains the divided ends in their normal line of direction, 
somewhat fixed, and favors their ultimate reunion. 

Grasp the metacarpus or metatarsus in this area from 
above and behind in such a manner that the thumb rests 
upon the median or upper surface, and the index and second 
fingers on the lateral or under side of the flexor pedis 
tendon. While the left thumb pushes the skin toward the 
bone, that is, forward, a sharp-pointed tenotome held per- 
pendicularly in the right hand is introduced with the cut- 
ting edge toward the body through the skin, subcutem and 
fascia down to the flexor pedis tendon. Immediately on 
the anterior border of the tendon, insert the tenotome so far 




«- en .is 



TENOTOMY OF FLEXORS OF PHALANGES 131 

that the point of it can be felt on the lateral or outer side 
through the skin with the left hand. 

Care is to be exercised in making this invading incision 
not to include the metacarpal, or metatarsal, arteries, veins 
and nerves. The vascular bundle lies immediately against 
the anterior border of the flexor of the third phalanx and 
it is easy to err by inserting the tenotome in front of the 
vessels, that is, between the suspensory ligament and vessels 
instead of between the flexor of the third phalanx and ves- 
sels. It is best to make the skin incision far enough pos- 
teriorly to insure safety to the vessels. First cut down upon 
the tendon, then incline the handle of the tenotome 
backward, push the point obliquely forward and down- 
ward behind and beneath the vascular bundle and then 
carrying the handle forward, bring the instrument to a per- 
pendicular position, and force it down along the ante- 
rior surface of the tendon until it nears the inferior border. 
Then carry the tenotome handle yet farther for- 
ward so that the point is directed obliquely backward, to 
facilitate its passing between the vessel bundle and the ten- 
don out to the skin. The invading incision thus describes 
the segment of a circle, with its concavity backward toward 
the tendon. 

The cutting edge of the instrument is then turned against 
the tendon, that is, it is directed backward, the foot is ex- 
tended by an assistant with the aid of a rope bound around 
the pastern and looped over the hoof, and the tendon is cut 
through under light pressure, the operator pressing the 
handle of the knife forward and downward, using the meta- 
carpus or suspensory ligament as a fulcrum upon which the 
back of the tenotome rests as a lever. A loud cracking, as 
well as the disappearance of resistance to extension, shows 
that the tendon has been severed. 

After removing the knife and seeing that there is a wide 
space between the ends of the tendon, the foot is unbound 



132 PERONEAL TENOTOMY 

from the splint and a bandage, which rests upon the fetlock 
joint, applied to the metacarpus, and allowed to remain in 
position for eight days. The cutaneous wound should heal 
by primary union. 



38. PERONEAL TENOTOMY 
Fig. 50 

Object. The relief of Stringhalt. 

Instruments. Razor, scissors, sharp tenotome. 

Technic. On the lateral side of the metatarsus a triangle, 
d, opening toward the tarsus is formed by the tendons of 
the extensor pendis longus muscle, /, and the lateral extensor 
of the foot, e, which unite on the anterior surface of the 
middle of the metatarsus. The synovial sheath of the ex- 
tensor pedis longus muscle extends inferiorly to near the 
point of juncture of the two tendons ; the sheath of the 
lateral extensor ends below, 3 to 4 cm. above the point of 
union. In the middle of this space without a sheath, which 
is 3 to 4 cm. long, and below the annular ligament of the 
hock, the operation is carried out. After the skin has been 
shaved and disinfected, confine in the stocks or operate 
upon the standing horse, with the aid of local anaesthesia, 
a twitch being applied to the nose and the opposite hind foot 
held up with the side-line. The tendon of the lateral ex- 
tensor is easily felt under the skin as a hard cord about 0.7 
to 1 cm, in diameter. Stretch the skin and with the back 
of the hand toward the hock, grasp and compress the tendon 
with the thumb and index finger of one hand, insert the 
tenotome with the cutting edge toward the body perpendicu- 
larly upon the tendon through the skin, subcutem and 
aponeurosis derived from the crural fascia ; push it from 
before backward under the tendon, turn the cutting edge 
against it, and with the hock extended, sever the tendon as 






m 




Fig. 50 

Peroneal Tenotomy for Stringhalt 

Right hind foot seen from the external side. The skin covering the 
lateral extensor of the foot is laid back in the form of a flap, the 
•crural fascia divided, e, Peroneal tendon ; f, crural fascia ; /, tendon 
of the 'anterior extensor pedis muscle ; d, the triangle formed by / 
and e. 



134 CUNEAN TENOTOMY 

well as the fascia through to the skin. In accomplishing 
the section of the tendon, the knife is to be used as a lever 
of the first class with the anterior border of the metatarsus 
acting as a fulcrum. If the tendon has been completely 
severed, its retracted ends may be felt under the skin i to 
2 cm. above and below the wound. After the operation an 
antiseptic bandage is applied, resting upon the fetlock. The 
bandage should remain eight days and the cutaneous wound 
heal by first intention. Care should be taken not to wound 
the tendon of the extensor pedis longus muscle. 

Recently it has been proposed to permanently obliterate 
the function of the peroneus muscle by severing it's tendon 
within it's tarsal sheath above and below the tarsus and 
withdrawing the isolated section. The same object may be 
attained by merely severing the tendon within it's sheath 
below the tarsus, if the operation be carried out under aseptic 
precautions, because when thus performed the epithelium 
advances over the retracted cut ends and leaves them free 
in the sheath. 



39. CUNEAN TENOTOMY 
FIG. 50 

Objects. The relief of spavin lameness. 

Instruments. Razors, scissors, straight scalpel, Peters' 
spavin knife. 

Technic. Most horses can be operated on standing, under 
local anaesthesia ; otherwise the horse should be cast, or 
secured on the operating table, on the affected side and the 
tarsus extended. Shave and disinfect an area 5 to 6 cm. 
square on the inferior median surface of the hock, over 
the course of the cunean tendon of the chief flexor of the 
metatarsus, as indicated in Fig. 51. locate the tendon, 
CT, by palpation as it passes obliquely downward and back- 
ward and make a transverse incision with a straight scalpel 




FIG. 51 

Cunean Tenotomy 

For the relief of spavin lameness. CT, Cunean tendon. The dotted 
line crosses the ergot. 



136 CUNEAN TENOTOMY 

or tenotome, in the form of a stab wound, merely 
sufficient to afford passage for the blade of the instru- 
ment, about i cm. below the inferior border of the tendon 
at a point midway between the anterior and posterior 
borders of the hock, or slightly anterior thereto. Push the 
tenotome flatwise between the skin and tendon, as shown in 
the figure, force it upward to the superior border of the 
tendon, then turn the cutting edge toward it and elevating 
the handle, using the superior border of the skin wound as 
a fulcrum, cut the tendon through from without inward. 
By firm pressure upon the skin over the tenotome, peri- 
osteotomy is simultaneously accomplished. The completion 
of the operation is evidenced by the separation of the cut 
ends of the tendon leaving a well-marked depression at the 
point of division. Disinfect the wound, apply an antiseptic 
pack covered by a tarred bandage resting upon the fetlock 
and including the hock, and allow to remain undisturbed 
for six days. A common, and perhaps better plan, is to 
follow the tenotomy with point firing, applying a can- 
tharides-biniodide of mercury blister. Cover with dry 
absorbent cotton and over this a tarred bandage which is 
allowed to remain eight days. Healing by primary union. 
After the incision through the skin has been made, the 
Peters' knife may be used instead of the straight scalpel, 
and the tendon and periosteum cut through at two or three 
different points, the cuts diverging upwards from the 
cutaneous wound, V-shaped. 



NEURECTOMY 137 



NEURECTOMY 

General Remarks. Neurectomy is performed for a variety 
of objects, such as the relief of pain in a sensitive nerve 
itself, as in trifacial neurectomy, p. 64 ; the relief of pain or 
lameness in a part supplied by a sensor} 7 nerve ; or the inhi- 
bition of motor power, as in the "cribbing" operation by 
severing the spinal accessory where it passes into the sterno- 
maxillaris muscle. 

The following neurectomies are designed to relieve pain 
and the consequent lameness dependent upon a pathologic 
condition of some structure, on the distal side of the point 
of operation and to which the divided sensory nerve is 
destined. 

Neurectomy of a sensory nerve is always a painful opera- 
tion, and it's performance without anaesthesia is unjustifi- 
able from a humane standpoint, and cannot be so well done 
either from a view of mechanical correctness or the carry- 
ing out of antiseptic standards. Some neurectomies can be 
well performed on the standing animal if it is quiet and the 
operator is experienced, the parts being rendered insensi- 
tive by means of local anaesthesia ; in the greater neurec- 
tomies, general anaesthesia ma5 7 be desirable or necessary 
from the humane or operative standpoint. 

The confinement of animals for neurectomy on the sensory 
nerves of the extremities for the relief of lameness," is always 
to be viewed as a critical procedure for the reason that the 
operation is generally made because of the local manifesta- 
tion of a more or less general disease which may be accom- 
panied by general fragility of the skeleton, and as a result 
most casting accidents occur in cases of confining for neu- 
rectomy or firing in cases of lameness belonging to the great 
group of dry arthritis or spavin family. Casting must, 
therefore, be done with the greatest possible care, and the 
operating table is to be greatly preferred. 



138 NEURECTOMY 



Neurectomy is properly a last resort in lameness and 
should not otherwise be performed. It has two great and 
ever present dangers. If the part deprived of sensation is 
too badly diseased to bear the weight and resist the insult 
resultant upon its being called upon to do its normal or 
even an extra amount of work, it must ultimately give way, 
the bones become fractured, the tendons separate from the 
bone, the intra-ungular tissues lose their integrity, and the 
hoofs become detached (exungulation) or other degenera- 
tive changes take place as a result of causing a part to do a 
work for which its condition unfits it. 

The second great danger occurs from wounds or other 
traumatisms to the tissues distal to the operation when the 
unnerved parts are not rested as they would be in natural 
conditions when injured, and as a result reparative changes 
are prevented and supplanted by retrograde processes with 
ultimate death of the part and of the animal. 

In other words, sensory neurectomy robs an organ or tissue 
of the enormously conservative force of pain. Pain causes 
the animal to rest the affected part, protects the painful 
tissues against disintegrating and destructive insults and 
favors restorative processes ; robbed of this protective in- 
fluence of pain by the severance of the sensory nerves, the 
diseased tissues are without their natural protection. 

Nerves are generally accompanied by satellite arteries 
and veins which are always liable to be wounded during the 
neurectomy and are more embarrassing because of the 
hemorrhage clouding the operation field and inviting error 
than dangerous because of the loss of the blood itself. It 
is essential to a good operation that the hemorrhage be kept 
under control throughout so that each tissue will stand out 
in relief and the nerve reveal it's identity in addition to its 
location, size and relations, by it's intensely white, nacrous, 
striated character. The test of compressing the nerve in 
order to identify it by the resultant pain is unsurgical and 
unnecessarily cruel. 



DIGITAL NEURECTOMY 139 

Sepsis holds an important place in considering the dangers 
of neurectomy because the infection of a sensitive nerve 
causes very great pain and if considerable, tends to cause a 
false neuroma or fibroma in the connective tissue of the 
nerve trunk, calling for a second operation in order to re- 
move the tumor, and resultant lameness. 

Neurectomies should consequently be performed only in 
properly selected cases, the smallest possible trunk that will 
sufficiently relieve the pain should be selected for the opera- 
tion, it should be performed with due regard for suffering 
and for asepsis, should be performed quickly and neatty, the 
incisions being free, laying the nerve trunk bare without tear- 
ing up the tissues and clouding them and at every point the 
operator should aim at celerity, accuracy and neatness. Neu- 
rectomy is frequently unethical and the veterinarian who 
values his good name, will be careful in selecting his clients 
as well as his patients. Some owners of lame horses have 
scant honor and ask the veterinarian to perform neurectomy 
for the fundamental purpose of masking serious disease until 
the animal may be sold. The veterinarian consciously or 
unconsciously becomes a party to the deceit. He should, 
therefore, operate only upon animals which he has ample 
assurance will not be fraudulently sold. In case of any 
question of the intent of the owner, he should be given 
clearly to understand that no rule of professional secrecy is 
binding upon the veterinarian and that under no avoidable 
circumstances will he become a partner in the fraud. 



40. DIGITAL NEURECTOMY 
Fig. 52 

Objects. The relief of navicular lameness in cases where 
plantar neurectomy is not deemed necessary or advisable. 

Instruments. Razor, scissors, scalpel, probe-pointed bis- 
toury, tenacula, aneurism needles, bandages, 



140 DIGITAL NEURECTOMY 

Technic. Digital neurectomy may generally be performed 
on the standing animal, the operative area having first been 
fully anaesthetized and adrenalin solution added to the local 
anaesthetic in order to control hemorrhage, a twitch applied 
to the upper lip and the affected foot held up by an assistant. 
If necessary because of restlessness of the animal or inex- 
perience of the operator, confine on the operating table or 
cast the animal and apply the extension splint to the foot 
to be operated on as shown in Fig. 49, page 130, except that 
the lower binding cords rest on the metacarpus instead of 
the pastern. 

Extending downward from the fetlock joint toward the 
coronet, between the posterior border of the first phalanx 
and the anterior border of the flexor tendons, there is a slight 
furrow, at the posterior part of which, close to the external 
margin of the tendon, lies the median or principal digital 
nerve accompanied in front by the digital artery, A, anterior 
to which lies the digital vein, V. Immediately behind the 
nerve and generally lying a trifle deeper, is quite commonly 
found a second venous trunk of considerable size. Near the 
middle of the first phalanx the nerve is crossed externally 
in an oblique direction from above to below and from behind 
to before by a white ligamentous baud, L, slightly broader 
than the nerve extending from the base of the ergot of the 
fetlock to the retrossal process of the pedal bone. This must 
not be mistaken for the nerve, N, and need not be if it is 
remembered that the latter is accompanied on the same plane 
and in a like direction by the satellite artery, A, and vein, 
V, enclosed with it in a fibrous sheath. At the uppermost 
part of the first phalanx the nerve lies in front of this liga- 
ment, a short distance inferiorly it passes beneath it, while 
from the middle of the pastern downward the nerve lies 
behind the ligament. 

The operation is practicable at any point over the line of 
the nerve from the top to the bottom of the shaved area in 




-N 



FIG. 52 
Digital Neurectomy 

V. Digital vein ; A, digital artery ; N, principal digital 
nerve ; L, ligament. 



142 PLANTAR NEURECTOMY 

Fig. 52 or from the superior end of the first phalanx down 
to a level with the superior border of the lateral cartilage, 
but preferably at about the point shown in Fig. 52, near the 
superior end of the first phalanx. At the desired point and 
over the groove between the flexor pedis tendon and the 
phalanges, shave and disinfect an area 4 to 5 cm. square. 
In the center of this area at the anterior border of the flexor 
tendon, with the scalpel held perpendicular to the skin, 
make an incision from above downward, a distance of from 
2 to 3 cm., cutting cleanly through the skin and subcutane- 
ous fascia down upon the nerve. The incision is favored 
by tensing the skin between the thumb and index finger of 
the left hand, but care should be taken not to displace it 
backward or forward. Dilate the wound by pressure upon 
the skin with the thumb and index finger or otherwise and 
carefully incise longitudinally the fibrous sheath enveloping 
the nerve and artery. Pass an aneurism needle beneath the 
nerve, and forcing it upward and downward, separate there- 
by the nerve from the surrounding tissues. Insert a probe- 
pointed bistoury or scissors beneath the nerve, divide 
it at the upper angle of the wound and excise a section 3 
cm. long. Disinfect and bandage with or without suturing 
the wounds. Leave the bandage in place 6 to 8 days. 



41. PLANTAR NEURECTOMY 
Fig. 53 

Object. The relief of navicular or ringbone lameness or 
other painful, non-suppurating disease of any parts below 
the fetlock joint, 

Instruments. Razor, scissors, convex scalpel, compres- 
sion artery forceps, tenacula, aneurism needles, suture ma- 
terial, elastic ligature. 

Technic. It is well to shave the site of operation and 
thoroughly disinfect the region of the metacarpus and fet- 
lock with soap, brush, and sublimate or creolin solution and 



PLANTAR NEURECTOMY 143 

50% alcohol, and apply a bandage saturated with sublimate 
or creolin solution to the fetlock joint 24 hrs. before the 
operation in order to secure an aseptic field. 

Confine the animal and fix the limb as in the preceding 
operation. After removing the disinfecting bandage, pro- 
ducing local anaesthesia and causing constriction of the 
arteries by adrenalin, pass the fingers from before to behind 
with light pressure over the region just above the fetlock 
joint, where there is felt immediately in front of the flexor 
pedis tendon a channel-like depression extending from 
above the fetlock downward over it. Just at the anterior 
margin of the flexor pedis tendon and at the posterior part 
of the groove, lies the cordlike vascular bundle, consisting 
from behind to before, of the nerve, ?i, 3 mm. thick, and of 
the plantar arteryand the vein v, which glides away from 
underneath the fingers with a distinct recoil. The site of 
operation lies immediately above the fetlock in the posterior 
third of the metacarpus. In special cases one may operate 
at any point higher up as far as beyond the middle of the 
metacarpus or metatarsus, so long as care is taken to include 
the anastomosing branch given off by the median plantar 
nerve at about the middle of the metacarpus and bending 
obliquely around behind the tendons to join the lateral 
nerve somewhat lower down. At the point designated stretch 
the skin between the thumb and index finger of one hand 
and make an incision 3 to 5 cm. long, the lower angle of 
which is usually just above the fetlock joint, cutting directly 
through the skin, subcutem and connective tissue sheath 
down onto the nerve, laying it bare. The borders of the 
cutaneous wound are held apart with teuacula and by pal- 
pation with the fingers or by vision it is determined if the 
nerve lies in the middle of the wound. If necessary con- 
tinue the dissection with the scalpel until the nerve is 
clearly revealed ; it is distinguished by its nacrous white 
•color, its fine longitudinal striae and its location immediately 
behind the metacarpal artery. 




N^ 



Plantar Neurectomy 

a, Lateral digital artery ; v, lateral digital vein ; », common lateral 
digital nerve ; d, anterior branch ; o, posterior branch ; s, superficial 
flexor tendon ; p, perforans tendon ; /, suspensory ligament of fet- 
lock ; ;;/, metacarpus. 



MEDIAN NEURECTOMY 145 

Immediately above the fetlock joint the median metacar- 
pal or metatarsal nerve divides into an anterior smaller, d, 
and posterior larger branch, o. This division should be laid 
bare in order that the operator may not erroneously cut one 
branch only. Immediately above this point of division the 
aneurism needle is passed under the nerve, pushed well 
through and forced up and down, separating the nerve from 
the adjacent tissues, the scissors or a small probe-pointed 
bistoury is passed beneath and it is cut through quickly at 
the superior angle of the wound. The distal end of the 
nerve is then dissected free downward and excised at the 
lower angle of the wound so that a section 3 to 5 cm. long 
is removed. The cutaneous wound is united by a suture 
and a temporary bandage applied. If the horse has been 
secured by casting, the extension splint, if it has been used, 
is then removed, the foot replaced in the hobble and the 
horse turned to the other side. The operation on the oppo- 
site metacarpal nerve is carried out in the same way after 
which a sterile bandage is applied and allowed to remain 
eight days. Healing by primary union. 



42. MEDIAN NEURECTOMY 
Fig. 54 

Objects. The relief of lameness due to disease so located 
in the anterior limb that it cannot be overcome by plantar 
neurectomy. 

Instruments. Razor, scissors, convex scalpel, artery and 
compression forceps, tenacula, aneurism needles, suture 
material. 

Technic. The operation is performed on the median 
surface of the anterior limb immediately below the humero- 
radial articulation on the recumbent horse after the affected 
foot has been fully extended on the operating table, or in de- 



146 MEDIAN NEURECTOMY 

fault of this, removed from the hobbles and bound upon the 
extension splint as shown in Fig. 54. Apply a local anaes- 
thetic with adrenalin. 

The foot is drawn out firmly from the shoulder, inclined 
somewhat forward. The operator places himself between 
the neck and the forearm of the patient and, after the 
median region of the elbow joint has been washed with soap 
and water, searches for the median nerve where it glides 
over the posterior part of the joint to disappear behind the 
radius. Shave the skin at and below this point, disinfect 
it with sublimate or creolin solution and 50% alcohol. The 
nerve, n, lies as a rule somewhat in front of the middle of 
the median side of the forearm against the postero-internal 
margin of the radius and can be felt, about 5 to 6 mm. in 
diameter, lying somewhat deeply. The position of the 
nerve varies with the different attitudes of the forearm. In 
fat and fleshy horses the identification of the nerve is more 
difficult. It may be felt upon the standing animal. 

With the thumb and index finger, stretch the skin over 
the nerve at the point where it begins to disappear behind 
the radius after having passed over the humero-radial 
articulation. Make an incision 5 cm. long, first through 
the skin, then through the expansion of the sterno- 
apoueuroticus muscle down upon the nerve. Check any 
hemorrhage from the skin, subcutis, or muscle. The tena- 
cula are inserted cautiously in the lips of the wound, and 
these being drawn apart, the white anti-brachial fascia is 
brought into view and a search is made with the index 
finger to determine the exact location of the nerve, the fascia 
is divided with the scalpel and an oval piece immediately 
over the nerve excised with the scissors. If much fatty 
tissue is found beneath the fascia, it may be dissected away 
carefully with the scalpel or cut away with the scissors. 
There now comes into view a delicate reddish colored fascia- 
like membrane, the nerve sheath, behind which a dark cord, 



MEDIAN NEURECTOMY 



147 



the brachial vein, V, is visible, the latter being intimately 
connected with the nerve sheath. The vein lies mostly be- 
hind and beneath the nerve and may project out from be- 
neath the border of the same. The operator needs to be care- 
ful not to prick this vein with the tenacula, as the hemorrhage 




FIG. 54 
Median Neurectomy 

Median surface of the right humeroradial articulation, a. Brachial 
artery ; ;/, median nerve ; z>, brachial vein ; f, antibrachial fascia ; 
p, sterno-apoueuroticus muscle. 

therefrom is exceedingly annoying during the operation. 
Avoid the use of te?iacula after penetrating the fascia and re- 
tract the wound lips cautiously with aneurism needles instead. 
Still further forward and deeper may be felt the pulsating 
brachial artery. Incise the nerve sheath carefully and 
divide it upward and downward with the scalpel or scissors, 



148 ULNAR NEURECTOMY 

whereupon the yellowish and distinctly striated nerve comes 
into plain view. Pass an aneurism needle beneath the 
nerve, pushing it so far through that the distal end is readily 
grasped and drawing it up and down with the two hands, 
separate the nerve from the adjacent tissues throughout the 
length of the wound. Be careful not to cut the nerve too high 
and erroneously include the motor nerve of the flexor of the 
metacarpus and the flexors of the foot, which is generally 
given off posteriorly just below the humero- radial articulatio?i. 
Lift the nerve up and cut it through at the superior angle 
of the wound by a sudden clip with the scissors or with the 
probe-pointed bistoury. Lay the peripheral end of the 
nerve bare to the lower angle of the wound, and excise at 
least 3 cm. of it. Disinfect the wound and approximate the 
skin with a continuous suture. The tampon and sutures 
remain i to 2 days. 

Since sensation of the lower part of the limb is partly 
maintained by the deep branch of the ulnar nerve which at 
the lower part of the carpus, covered by the tendon of the 
oblique flexor, becomes the lateral plantar nerve, neurectomy 
of the median nerve does not always completely effect the 
desired end. In order to produce complete anaesthesia of 
the foot, therefore, it is necessary to perform ulnar 
neurectomv also. 



43. ULNAR NEURECTOMY 
Figs. 55 , 56 

Object. An adjunct operation of the preceding by which 
the enervation of the carpus and foot is completed, 

Instruments. Same as the preceding. 

Technic. Above and behind the carpus there may be 
felt a groove between its external and middle flexors, EF 
and OF, Fig. 55. At this point, 10 cm. above the pisiform 




FIG. 55. 
Ulnar Neurectomy 

Right forearm seen from behind. <\ External flexor of the carpus ; 
y, oblique (middle) flexor of the carpus ; a, collateral ulnar artery ; 
b, antibrachial fascia ; ;/, ulnar nerve.. 






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152 SCIATIC NEURECTOMY 



bone, the skin is shaved and disinfected and an incision 6 
cm. long made through the skin and antibrachial fascia. 
This incision extends just outside the median line of the 
posterior surface of the radius in such a way that the supe- 
rior angle of the wound is about i cm. farther outward 
than the lower. Beneath the fascia between the aforesaid 
muscles is seen the ulnar nerve, Fig. 55, n ,Fig. 56, NU, on 
the median or inner side of it, the collateral ulnar vein, Fig. 
55, v, and between the two and somewhat deeper, the col- 
lateral ulnar artery, a. The nerve, about 3 mm. in diame- 
ter, is picked up with the aneurism needle, severed at the 
upper and lower angles of the wound, the lips of the wound 
united by a continuous suture and a bandage applied. 
Healing takes place by first intention. 



44. SCIATIC NEURECTOMY 
Figs. 57, 58 

Objects. The destruction of sensation in the tarsus and 
parts beyond for the relief of otherwise incurable spavin 
lameness, diseases of the tendons, etc. 

Instruments. Same as in the preceding. 

Technic. Expert surgeons may operate on the standing 
animal under local anaesthesia and adrenalin. The average 
operator should place the animal on the operating table on 
the diseased side, extend the affected limb and draw the 
upper leg forward or backward and secure it out of the way. 
Produce complete general or local anaesthesia. The posterior 
tibial or sciatic nerve, n, Fig. 57 and NS, Fig. 58, is then 
sought by grasping the leg with the left hand from behind in 
such a manner that the thumb rests above and the fingertips 
below it. Reaching forward with the fingers to the deep 
flexor of the foot, grasp the leg with moderate firmness and 
draw the hand slowly backward. Immediately behind the 



SCIATIC NEURECTOMY 



perforans muscle and between this and the tendo- Achilles 
the nerve, nearly i cm. in diameter, glides away forward 
from between the fingers with a distinct recoil. If the nerve 
cannot be recognized in this manner, the hock should be 
more strongly extended, by which means it may be caused to 




FIG. 57 
Sciatic Neurectomy 

Right hind leg viewed from the median side,/ Crural fascia ; », 
sciatic (tibial) nerve ; z\ plantar vein. 

recede from the perforans muscle, so that it can more readily 
be felt near the middle of the groove extending between it 
and the tendo- Achilles. 

At this point on the median side of the leg the skin is 
shaved, disinfected and an incision made through it, 5*cm. 



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156 ANTERIOR TIBIAL NEURECTOMY 



long, parallel to the teudo-Achilles. The white, rigidly- 
stretched crural fascia is now divided in the same direction, 
after which the precise location of the nerve should be de- 
termined by palpation. Excise with the scissors an elliptic 
or oval piece of the fascia directly over the nerve, or hold 
it apart along with the lips of the cutaneous wound by 
means of the tenacula. In poor horses the contour of the 
nerve, covered only by loose connective tissue, stands out 
prominently ; in fat horses it is surrounded by a large amount 
of adipose tissue. Cut through this fat and connective tissue 
and expose the tibial nerve, n, Fig. 57, and NS, Fig. 58, 
to view ; immediately before it, lies the plantar vein and 
on the lateral side is situated the recurrent tibial artery, 
SA, Fig. 58. The cross section in Fig. 58 is located some- 
what below the point for operation and the vein has crossed 
obliquely over the nerve so that it appears behind instead of 
hi front of it, as is the case generally at the point where the 
operation is performed. Separate the vessels completely 
from the nerve with the handle of the scalpel, pass an 
aneurism needle from before backward beneath it through 
to the handle and grasping both ends, force the instrument 
upward and downward in order to separate the nerve trunk 
from the adjacent tissues. Cut the nerve off at the upper 
and lower angles of the wound, removing a section at least 
5 cm. long. Suture the cutaneous wound and apply a 
bandage allowing it to remain eight days, Healing should 
occur by first intention. 

45. ANTERIOR TIBIAL NEURECTOMY 

Neurectomy of the Deep Branch of the Peroneal Nerve 
Figs. 58, 59 

Object. An adjunct operation to the preceding, since this 
nerve supplies sensation to the tarsus in common with the 
sciatic. The two constitute what is known as Bossi's double 
neurectomy for spavin. 

Instruments. Same as in the preceding. 




FIG. 59 

Anterior Tibial Neurectomy 

EP. Extensor pedis muscle ; P, peroneus muscle ; XP, deep branch 
of the peroneal or anterior tibial nerve ; PM, flexor metatarsi muscle. 



158 ANTERIOR TIBIAL NEURECTOMY 

Technic. Confine as in the preceding but with the affected 
leg uppermost. Locate the furrow dividing the extensor 
pedis longus, EP, Figs. 58, 59, and the peroneus muscles, P, 
Fig. 58, MP, Fig. 59, and shave and disinfect an area 6 cm. 
long by 3 cm. wide directly over this depression and ex- 
tending upward from a point 6 to 7 cm. above the tibio- 
astragaloid articulation. 

At a point 8 to 10 cm. above the flexure of the hock, make 
an incision through the skin and subcutis 5 or 6 cm. long 
over the line of division between the two extensors of the 
foot. Superficially the operator passes near by the musculo- 
cutaneous division of the anterior tibial nerve, NMC, 
Fig. 58, which must not be mistaken for the deep branch. 

The peroneus muscle, MP, Fig. 58, and P, Fig. 59, is 
separated from the extensor pedis longus, EP, Figs. 58, 
59, by a strong aponeurotic sheath continuous with 
the tibial aponeurosis. Penetrate the tibial aponeurosis 
anterior to the aponeurotic partition directly against the 
extensor pedis, EP. Passing along the posterior border of 
this muscle to a depth of 2 to 4 cm., there appears the thin 
margin of the flexor metatarsi magnus, FM, Figs. 58, 
59, which lies immediately against the extensor pedis 
without a visible connective tissue partition but reveals it- 
self by a markedly lighter shade of color and its ready 
separation from the extensor with the scalpel. The deep 
branch of the peroneal nerve, NP, Figs. 58 and 59, lies 
loosely imbedded on the anterior side of the margin of the 
flexor metatarsi facing the extensor pedis, at times visible 
at the margin, at others placed more deeply, reaching in 
some cases a distance from the margin of 4 or 5 mm. 
Within this range is seen the slender nerve trunk almost 
devoid of surrounding connective tissue and measuring 
about 2 mm. in diameter. Pass the aneurism needle beneath 
it and remove a piece 3 to 4 cm. long. Close the cutaneous 
wound with interrupted sutures and dress antiseptically 
without a bandage. 



RESECTION OF THE LATERAL CARTILAGE 159 

46. RESECTION OF THE LATERAL CARTILAGE 
The Bayer Q,uittor Operation 
Figs. 60, 61 

Object. The cure of quittor or necrosis of the lateral 
cartilage. 

Instruments. Elastic ligature, drawing knife, scissors, 
razor, hoof rasp, hoof plane, craniotomy or other heavy for- 
ceps for the removal of the horn, artery forceps, elevator or 
long bone chisel, right and left sage knives, curette, needle 
holder, thread, needles, antiseptic gauze, tampons, absorb- 
ent cotton, bandages. 

Technic. For a few hours before the operation place the 
affected foot in a bath of creolin or other antiseptic solution, 
after having first rasped the diseased quarter lightly and 
having made a semicircular groove in the horn of the lateral 
wall and quarter down to the horny lamina, as shown at s 
in Fig. 6o. It is essential not to materially thin the horn on 
the quarter with the rasp since by weakening it, it yields 
and breaks and cannot be properly detached from the sensi- 
tive laminae. The rasping of the wall should merely suffice 
to remove the very hard external layer and facilitate the 
cutting of the groove with the hoof knife. 

The operation is performed upon the recumbent, anaes- 
thetized animal, in such a position that the diseased carti- 
lage of the affected foot lies upward. The operating table 
constitutes incomparably the best means of confinement in 
every respect. 

The hair on the coronary band is clipped or shaved and 
the entire foot up to the fetlock joint thoroughly cleansed 
with brush, soap, creolin or sublimate solution and 50 per 
cent, alcohol. The fetlock and pastern are carefully 
wrapped in a towel saturated with sublimate solution or 
other disinfectant. The hoof should be similarly wrapped 



160 RESECTION OF THE LATERAL CARTILAGE 

except the operative area and ever} 7 precaution taken against 
the transfer of infecting material from neighboring parts 
into the wound. 

After the application of the elastic ligature in the meta- 
carpal or metatarsal region, the groove in the horn is deep- 
ened with the drawing knife down to the sensitive laminae 
without injuring them. The groove must be so located 
that it extends beyond the anterior and posterior borders of 
the lateral cartilage, and downward to within i or 2 cm. of 
the margin of the os pedis and approximately perpendicu- 
lar to the surface of the horn wall so that it will form a 
secure support for the dressing to be later applied. 

The elevator or long bone chisel is then inserted beneath 
the lowest part of the semi-circular piece of horn which has 
been isolated, the horn is elevated from the sensitive struc- 
tures somewhat, grasped with the heavy forceps and care- 
fully loosened from the sensitive parts by drawing upward 
parallel to the laminae until the coronary band is reached. 
The traction is then directed backward toward the heel, 
separating the wall from the coronary papillae and kera- 
phyllous tissue. Care is to be taken here to avoid lacerat- 
ing the underlying tissues, especially when the traction is 
first directed backward. If the soft tissues threaten to 
tear, the danger should be avoided by the timely use of the 
scalpel or sage knife as conditions may suggest. 

After the coronary band has been smoothed with the 
scissors, make two perpendicular incisions through the skin 
and coronary band, one behind the anterior and the other in 
front of the posterior border of the groove in the horn, and 
connect the two by means of a semi-circular incision in the 
sensitive laminae. The U-shaped incision should be so 
made that between it and the horny wall there is left an 
area of sensitive laminae 1 to 2 cm. wide, in order that there 
may be sufficient room in the soft tissues for the application 
of the sutures, as shown in Fig. 61. The lines of incision 




FIG. 60 

Resection of the Lateral Cartilages of the Os Pedis 

Horny wall removed, sensitive laminae and cutaneous flap held 
upward Posterior half of the cartilage excised, f, Sensitive lam- 
inae ; w, coronary band ; k, anterior half of cartilage ; //, cavity 
caused by the removal of the posterior half of the cartilage ; //, necrotic 
cartilage ; />, parachondral surface of the skin and sensitive lamime ; 
s, perpendicular, crescent-shaped incision in the horny wall ',£, fistula. 




FIG. 61 

Resection of the Lateral Cartilages of the Os Pedis 

Completed operation showing the sutures in place and the parts 
ready for the application of dressings. 



RESECTION OF THE LATERAL CARTILAGE 163 

through the coronary band should be so located as to in- 
clude between them the entire lateral cartilage. 

The isolated flap is now dissected closely against the os 
pedis and its ala and from the lateral surface of the carti- 
lage, the operator lifting the flap with forceps or tenaculum. 
Above the cartilage toward the fetlock the operator must 
keep the fingers of one hand against the external skin in 
order to avoid cutting through it or thinning it too much. 
The flap is held turned upward by an assistant or a strong 
suture is passed through it and turning it upward, the 
suture ends are carried around the pastern and tied. 

As a rule there is now seen a prominent, greenish colored, 
necrotic piece of cartilage surrounded by brownish red 
masses of granulations. By means of an incision through 
the cartilage parallel to the long axis of the foot, divide it 
into anterior and posterior halves and extirpate the latter 
first by dissecting it out on the inner side from the para- 
chondral tissue with the sage knife. Begin the excision of 
the cartilage by engaging the supero-anterior angle of the 
posterior half with the tenaculum and, exerting moderate 
traction, dissect it away from the underlying tissues first 
along the line of the dividing incision down to the base and 
then cut backward toward the heel cutting the cartilage 
away from the bone with which it is continuous. The 
point of the knife must be constantly directed against the 
cartilage. 

Since the inner surface of the anterior half of the cartilage 
lies immediately against the capsular ligament of the corono- 
pedal articulation, the joint should be sharply extended by 
having an assistant seize the toe and force it forward. By 
this means the capsular ligament is drawn away from the 
cartilage during its extirpation. 

The anterior half of the cartilage, k, is then removed in 
the same way, except with the greatest possible care to 
avoid puncturing the corono-pedal articulation. The chief 
precaution is to dissect onlv with the point of the sage knife, 



164 RESECTION OF THE LATERAL CARTILAGE 

using at all times that knife, right or left, which will result 
in its concave surface being presented toward the cartilage ; 
then by carefully keeping the line of excision immediately 
against the cartilage, material danger of penetrating the 
joint is avoided. Remnants of cartilage at its juncture with 
the retrossal process of the os pedis, and any granulations 
present are to be removed with the curette. Cut away with 
the scissors and knife any remnants of cartilage adherent to 
the flap, p, thin if necessary the entire flap and excise the 
fistulous openings, g. After thorough disinfection of the 
entire field of operation, return the flap to its former posi- 
tion and retain it there by a sufficient number of interrupted 
sutures as shown in Fig. 61. The first sutures to be applied 
should be at the border line between the skin and coronary 
band in order to insure accurate apposition at this point. 
Disinfect the wound surface with two per cent, chlorazene 
-solution. Pack the cavity remaining after the removal of 
the cartilage with powdered boric acid. Cover the entire 
surface with gauze saturated with two per cent, chlorazene, 
cover with dry cotton to prevent evaporation and over this 
apply a tar bandage. Remove the elastic ligature. If the 
animal is free from fever, feels and eats well, the bandage 
is left in position from 12 to 14 days. Healing by first 
intention. 

The two chief dangers in the operation are the opening 
of the corono-pedal articulation and the persistence of a 
scar in the coronary band resulting in a quarter crack. 

If the operation has been kept thoroughly antiseptic, the 
opening of the articulation is not necessarily serious. 

The question of preventing a weakening scar at the coro- 
nary incision is one of strict antisepsis and accurate sutur- 
ing. The operation frequently fails under indifferent 
technic. It is an operation for the careful surgeon only. 
In the succeeding modification of the quittor operation, the 
danger from a weak scar or a fissure in the coronary band 
is obviated and in this respect is to be preferred. 



MODIFIED QUITTOR OPERATION 165 

47. MODIFIED QUITTOR OPERATION 

A section of the horny wall is removed as in the Bayer 
opeiation. 

A semicircular incision is made through the sensitive 
laminae up to the coronary baud, care being taken not to 
injure the latter. This incision should be so made that 



3- 
2 




P 



FIG. 62. Modified Quittor Operation 

r. Cutaneous incision ; 2, incision through sensitive laminae ; 3. 
coronary band ; 4, sensitive laminae flap ; 5, sensitive lamina border 
to which flap is to be sutured ; 6, skin flap. 

there is left sufficient room between it and the horny wall 
for the application of sutures in the sensitive laminae. 

The flap thus formed is then dissected away from the os 
pedis and the lateral surface of the cartilage. By working 
beneath this loosened flap, the coronary band may be sepa- 



166 



MODIFIED QUITTOR OPERATION 



rated from its attachments for a distance equal, and corre- 
sponding to, the width of the flap. 

Another semicircular incision is then made through the 
skin over the upper border of the lateral cartilage beginning 
at the coronary band, j or 2 cm. in front of the anterior in- 
cision in the sensitive laminae. The incision is carried 
back about the same distance beyond the posterior incision 
in the laminae. 



/#' 



. \ 




FIG. 63. Modified Quittor Operation 

Figures same as in preceding. 

The upper flap is then dissected away from the surface of 
the cartilage, making a communication between the upper 
and lower incisions and leaving the cartilage exposed. 

The operation is then continued as in the Bayer method. 
The sutures are applied first to the sensitive laminae and 
then to the incision through the skin. 



RESECTION OF THE FLEXOR PEDIS TENDON 167 

48. RESECTION OF THE FLEXOR PEDIS TENDON 
Fig. 64 

Object. The removal of necrotic tissues and disinfection 
of the parts in cases of infected wounds, chiefly of nail 
wounds of the navicular bursa. 

Instruments. Elastic ligature, drawing knife, sage knives, 
scissors, tenaculum forceps, curette, scalpels, tenaculae, 
bandage material. 

Technic. Thin the horn of the sole, frog and bars until 
every part of the horny covering of the sole is thin, soft, 
and yielding. If opportunity offers, apply an antiseptic 
bandage for 24 hours. Secure the patient on the operating 
table or by casting in lateral recumbency with the affected 
foot extended. Anaesthetize. Cleanse and disinfect the 
entire foot with soap, brush, creolin or sublimate solution 
and 50% alcohol and apply the elastic tourniquet in the 
metacarpal or metatarsal region. Apply towels saturated 
with antiseptics as in preceding operation. Make a trans- 
verse incision through the base of the frog, 2 to 3 cm. from 
the balls, through the horny and sensitive portions and the 
fatty cushion down to the flexor pedis tendon. Follow this 
by two converging incisions extending forward and inward 
in an oblique direction corresponding to the semi-lunar crest 
of the os pedis, the lines of incision being in the bars about 
Y? cm. outward from the lateral groove of the frog and 
uniting at its apex. The triangular piece of frog which 
has been isolated by the incision is now grasped with the 
tenaculum and dissected away. The remnants of the fatty 
frog should be removed with the sage knife or scalpel by 
means of a horizontal incision. There is then revealed the 
flexor pedis tendon which may be greenish or yellowish 
colored and necrotic, or may be covered with reddish- 
colored granulations. 

Should there be present also suppurative pododermatitis, 
the bars on the affected side must be excised along with 
the other portions. 



168 



RESECTION OF THE FLEXOR PEDIS TENDON 



The position and extent of the navicular bone can now be 
determined by palpating it through the flexor tendon. A 
transverse incision is then made over the middle of the navi- 
cular bone through the flexor pedis tendon into the navicular 
bursa, the distal end of the tendon grasped with the tenaculum 
forceps and lifted up from the navicular bone with the aid 
of two lateral curved incisions. Between^the inferior or 




FIG. 64 

Resection of the Flexor Pedis Tendon 

Solar surface of the foot, r, Semi-lunar crest of os pedis ; a, os 
pedis ; r, navicular-pedal ligament ; s, navicular bone ; b, flexor 
pedis tendon ; <?, sensitive laminse of the bars ; st, fatty frog ;f, sensi- 
tive froj; ; h, horny frog. 

anterior border of the navicular bone and.^the semi-lunar 
crest of the os pedis, stretches the capsular ligament of the 
corono- pedal articulation reinforced by dense fibrous bands. 
The flexor pedis tendon is united to this by a few bundles of 
fibres. Dissect the tendon carefully away from the capsular 
ligament, avoiding opening the articulation, and then cut it 
away from the semi-lunar crest of theos pedis. If necrotic 



AMPUTATION OF THE CLAWS OF RUMINANTS 169 

or discolored pieces of the fatty cushion or the tendon still 
remain, remove these with scissors, scalpel or curette. 
Curette away all the cartilage from the inferior surface of 
the navicular bone and remove any necrotic or inflamed, 
softened portions of the bone. In extensive necrosis of the 
suspensory ligaments of the heel and of the ligaments ex- 
tending from the fetlock joint to the lateral cartilages, the 
necrotic portions as well as the neighboring fatty cushion 
with its numerous elastic fibres, must be resected. Incase 
of purulent areas extending along the tendon and opening 
above in the heel, draw through the tract a large strip of 
gauze thoroughly saturated with tincture of iodine and 
allow it to remain. If the suppurating area extends well 
up into the heel without an opening, incise from above and 
handle as preceding. Dress the wound as advised for 
the quittor operation on page 164. In the absence of fever 
the bandage remains in position for 12 to 15 days. 



49. AMPUTATION OF THE CLAWS OF RUMINANTS 
Figs. 65, 66 

Uses. The cure of "foul in the foot" or panaritium 
when complicated with suppurative arthritis or ostitis. 

Instruments. Half round rasp, sage knives, scissors, con- 
vex scalpel, artery forceps, drawing knife, elastic ligature, 
dressing materials. 

Technic. Cast the animal and secure the foot to be 
operated upon in an extended position, apply the elastic 
ligature and after disinfecting the claws, rasp away the horn 
on the lateral side of the diseased claw, especially at the 
posterior part of it, until the horny wall becomes so thin 
that it can readily be pressed in with the fingers. Anaes- 
thetize. The corono-pedal articulation can be felt, about 
3 cm. below the coronary band, by grasping the claw with 
the left hand in such a manner that the thumb rests upon 



170 



AMPUTATION OF THE CLAWS OF RUMINANTS 



the thinly rasped horn while with the other hand the claw 
is moved from side to side. At the lowest point of the 
articulation push the sage knife into the joint, the concavity 
of the knife being directed toward the leg, and make a 
curved incision at first forward and upward to the 
coronary band, then with strong flexion of the foot, 
a second curved incision backward and upward which, 
however, extends only to the navicular bone. By this in- 




FIG. 65. Amputation of the Claws of Ruminants 

d. Horny wall, rasped thin ; g y articular condyle of 2nd phalanx ; 
a, b, c, course of incision. 

cision the operator divides the horn, the sensitive lamina, 
the external corono-pedal ligament and the capsular liga- 
ment of the corono-pedal articulation. Pass the knife be- 
tween the navicular and pedal bones and extend the inci- 
sion downward perpendicular to and, through the sole, sepa- 
rating the navicular bone from the os pedis. In this man- 
ner the navicular bone is preserved as well as the ball of the 
heel, the latter of which is of special significance in healing. 



AMPUTATION OF THE CLAWS OF RUMINANTS 



171 



The inner wall of the claw with the powerfully developed 
corono-pedal ligament is divided from before backward. 
After the vessels which can be seen are ligated, the articu- 
lar surfaces of the navicular and coronary bones curetted 
and the necrotic remnants of tendon removed, an antiseptic 
pack is applied and a tar bandage placed over it for protec- 
tion. The bandage should remain for 12 or 14 days. 




FIG. 66 Amputation of Claws. 

P Median claw preserved. Viewed from the solar surface outward. 
a, External corono-pedal ligament ; i, internal do. ; £, tendon of the 
flexor pedis muscle ; g y distal articular surface of the 2nd digit : g ' 
articular surface of 3rd digit ; g f \ navicular bone ; /, lateral claw ; 
j?i, median claw ; />, bulb of the heel. 

If the structures above this point of amputation be irre- 
mediably involved, the digit should be amputated higher 
up, at the articulation of the first and second phalanges or 
through the first phalanx. In these higher amputations a 
flip operation is generally practicable. 



172 THE BAYER SUTURE 

50. THE BAYER SUTURE 
Fig. 67 

Uses. The closure of large or penetrant wounds with 
convenient and secure means for applying and retaining 
antiseptic dressings. 

Instruments. Large curved suture needle armed with 
strong silk thread, about 20 cm. long, which is doubled and 




FIG. 67 Retention, and Continuous Approximation Sutures 

d, d' ', d // , Drainage tubes ; e, retention suture (closed end) ; e' ', open 
end ; b, fixation suture for the drainage tube ; f, continuous approxi- 
mation suture. 

passed through the needle eye in such a manner that the 
loop extends considerably beyond the cut ends ; small 
needles and thread ; needle forceps ; rubber tubing, prefer- 
ably two large pieces and one small with lateral openings; 
thin wooden splints 15 cm. long, 2 to 4 cm. wide, with 
rounded ends ; antiseptic gauze ; antiseptics. 

Technic. After the skin has been shaved over an area 
having a radius of 5 to 6 cm. from the wound, the suture 



THE BAYER SUTURE 



173 



needle is inserted 2 to 3 cm, from the lips through the skin 
and adjacent tissues, a piece of the rubber tubing, d\ passed 
through the closed end of the suture and the thread drawn 
tight. If before threading the needle, a clove hitch be made 
at the middle of the thread, or if threaded as above directed 
and the thread be thrown about the tube in a double noose, 
the two threads will be kept in contact as they leave the 
tube to enter the soft tissues and thus prevent to some 




FIG. 68. Splint Bandage. 

d, d / , d", Drainage tubes ; <?, retention suture (closed ends) ; e\ do, 
open end ; /, antiseptic gauze ; s, splints. 

degree, the pressure necrosis otherwise taking place, due to 
the tense threads of the suture separating from each other. 
The needle is then passed through the opposite lip of the 
wound from within to without at the same distance from 
the lips, the needle removed, the free ends drawn taut and 
a single knot tied against the skin to prevent the separation 
of the two threads for the reasons just stated above. The 



174 THE BAYER SUTURE 



second large tube, d" , is laid between the open ends of the 
double silk thread and these are tied upon it with a triple 
knot, after they have been drawn sufficiently tight that the 
approximated wound lips form a crest. If the lips of the 
wound can be grasped with the hand and held together in 
such a manner as to form a ridge 3 or 4 cm. deep, the suture 
needle may be passed through both simultaneously. The 
first suture should be located about 3 cm. beneath the upper 
angle of the wound, the other retention sutures follow at 
distances of about 5 cm. from each other and are applied in 
the same way. 

The lips of the wound are then united by continuous ap- 
proximation sutures like an overcasted seam. This suture 
ends at least 2 cm. above the lower angle of the wound. 
The third tube, for drainage, is introduced beneath the latter 
sutures and fixed by a separate suture. 

The entire cutaneous surface lying between the drainage 
tubes is covered with antiseptic gauze, and between each 
two retention sutures there is laid over this gauze the 
wooden splints previously cut to the proper size, the ends of 
which are pushed under the tubing. The upper and lower- 
most splints should be secured to the tubing by means of 
sutures passed through them. The entire bandage is finally 
saturated with antiseptics. The bandage and retention 
sutures should remain eight days, the approximation sutures, 
fourteen. 



B. EMBRYOTOMY OPERATIONS 

Fig. 69. 

The following exercises in embryotomy operations are 
designed to give to the student a general view of the sub- 
ject by a simple plan as carried out through the aid of a 
skeleton provided with an artificial uterus into which are 
placed freshly killed, newly born calves in such a position 
as may be desired and the operations carried out by the 
student. At the same time it is hoped to offer to the veteri- 
nary obstetrist, through these descriptions, a simple and 
effective plan for performing embryotomy which has been 
fully tested by the author in an extensive obstetrical prac- 
tice. In describing these operations the instruments to be 
used are purposely limited to the fewest number and sim- 
plest kinds, essential to their performance. The same 
instruments are designated for each operation. 

They are, see Fig. 69 : a hooked ring knife ; a Colin's 
scalpel ; an embryotomy chisel ; long blunt hook ; short 
blurt hook ; repeller ; probe-pointed sector ; injection 
pump ; mallet ; several cotton ropes 1 cm. in diameter with 
a small, spliced loop at one end. 



51. CEPHALOTOMY 

Object. The diminution of the size of the head on ac- 
count of its oversize or the smallness of the maternal pelvis, 
so that it may pass through the pelvic canal. 

Technic. In these cases the head is usually engaged in 
the canal sufficiently tight that no further fixation is neces- 
sary. Should further fixation be desired, fix the long blunt 
hook deeply in one orbit. After thoroughly washing and 
cleaning the parts inject into the vagina a copious amount 
of tepid emollient like suspensions of elm bark or linseed, 
or apply fats like lard, oil, or vaseline in order to 
facilitate manipulations. Carry the chisel, carefully guarded 
by one hand, into the passage and place it accurately upon 



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FIG. 69 
Aseptible Embryotomy Outfit 

A. Embryotomy chisel ; B, repeller ; C, sector; D, long blunt hook ; 
R, short blunt hook ; F, ring knife ; G, hook knife ; H. Colin's scalpel 
The lower figure represents the entire set with injection pump arranged 
in aseptible metal case. 



DECAPITATION 177 



that part of the head of the fetus where it is desired to begin 
the operation ; generally on the median line of the nose 
with the blade of the chisel standing parallel to the septum 
nasi of the fetus. Holding the blade of the chisel firmly 
against the part with one hand in such a manner as to 
effectively guard the instrument from slipping aside and 
wounding the maternal organs, steady and direct the handle 
with the other hand and have an assistant drive the chisel 
by means of blows of proper vigor with the mallet into the 
bones of the face and head. Do not drive the chisel deeper 
than the length of the blade without stopping and forcibly 
revolving it upon its long axis and breaking the fetal bones 
apart. The partially detached pieces of bone may be torn 
away with the fingers or, in case the skin is quite adherent 
to them, the bone may be held with the fingers of one hand, 
the chisel introduced with the other and, using it as a spatula, 
the separation completed. The removal of the partially 
detached pieces of bone may in many cases be greatly facili- 
tated by looping a cord over them and having an assistant 
apply traction sufficient to pull them away, the operator 
guarding the maternal organs by holding the piece of bone 
during its detachment and extraction, in the palm of his 
hand. Repeat the use of the chisel as often as may be 
necessary in order to bring about the required diminution 
of the head, care being taken at all times not to wound the 
maternal parts and to conserve as far as practicable the skin 
of the fetal face and head in order that it may protect the 
maternal parts from jagged bones during the passage of the 
remains of the head. 

52. DECAPITATION 

Objects. The facilitation of repulsion and correction of 
the deviation of fetal parts. The operation is generally 
carried out when the fetal head is far advanced in the pelvic 
canal or has passed beyond the vulva. 



178 SUBCUTANEOUS AMPUTATION OF ANTERIOR LIMBS 

Technic. Attach a cord to the inferior maxilla of the 
fetus and have one or more assistants draw the head out as 
far as possible. 

Some obstetrists have found difficulty in applying traction 
to the inferior maxilla by means of a cord. First make a 
perforating wound with the knife between the rami of the 
lower jaw, then carry the looped cord over the jaw and push 
it beyond the perforating incision with the loop resting 
within the mouth, and finally pass the free end of the cord 
through the perforation from the buccal cavity outward, 
and drawing upon this the inferior maxilla is so engaged 
that it will permit the application of powerful traction. 

Make a circular incision at a convenient point through 
the integument encircling the head and separate the skin 
backward toward the occiput by forcing the hand between 
it and the bones or by using the chisel as a spatula or 
dissecting it away with the Colin's scalpel, continuing the 
separation over the occiput to the atloid region. Make a 
transverse incision below across the trachea and esophagus 
and surrounding muscles and above through the ligamentum 
nuchae. Grasp the head firmly with both hands and twist 
it forcibly on its long axis rupturing the articular ligaments 
and the remaining muscles and other soft tissues, detaching 
the head at the occipito-atloid articulation. The removal 
of the head greatly diminishes the bulk of the fetus and it 
may now be repelled, or deviated parts brought into the 
desired position and other operations performed. 



53. SUBCUTANEOUS AMPUTATION OF ANTERIOR 
LIMBS 

Objects. Amputation of the anterior limbs is very fre- 
quently called for in equine obstetric practice, chiefly in 
cases of transverse presentation with all four feet presenting 
and the head retained where it may be impossible to safely 
correct the deviation, in cases of wry neck in the foal in the 
anterior presentation, when it is impossible to correct the 
deviation of the head, or in any case in the mare or cow 



SUBCUTANEOUS AMPUTATION OF ANTERIOR LIMBS 179 



where deviation of the head cannot be corrected or is not so 
readily overcome as is the amputation of the limb. 

Technic. Herbivorous animals being devoid of a clavicle, 
the anterior limb is attached to the thorax by means of the 
skin and muscles only and is therefore comparatively easily 
amputated. Attach a cord to the pastern of the limb, the 
shoulder of which lies most exposed or is most readily 
reached and have one or two assistants exert traction on it 
and draw it out as far as possible with safety to the mother. 
Insert one hand armed with the hooked embryotomy knife 
up to the top of the scapula or as nearly thereto as can be 
reached, the knife being well guarded in the palm of the 
hand which rests against the limb of the fetus ; press the 
knife into the skin and subcutaneous tissues and drawing 
the hand downward slit them freely and deeply from the 
top of the scapula down to the pastern. Lay aside the 
knife and force the ringers between the skin and subjacent 
tissues of the limb and while an assistant maintains gentle 
traction, separate the skin upward by forcing the hand or 
the ball of the thumb through the loose connective tissue 
until the upper region of the scapula is reached. The sepa- 
ration of the skin from the subjacent parts may require at 
certain points, like the olecranon or carpus, the aid of the 
chisel or knife to divide firm bands of connective tissue. 
The separation of the skin from the subjacent parts has 
removed the chief source of resistance to the tearing of the 
limb away from the body. The skin is not to be severed 
from the foot until it has been completely detached from the 
leg and shoulder. The attachment of the skin to the foot 
gives it a neccessary fixation enabling the operator to detach 
it from the leg and shoulder by forcing the hand or other 
object upward between the skin and subjacent muscles. 
The next most important obstacle is the pectoral muscles 
which should be torn asunder by separating them into small 
bundles and tearing them through with the fingers between 
the sternum and limb, or the process may be aided by in- 



180 SUBCUTANEOUS AMPUTATION OF ANTERIOR LIMBS 



cision with a knife or the chisel. When these are well 
divided, the remaining impediment to tearing the shoulder 
away consists largely of the trapezius and rhomboideus 
muscles at the top, the latissimus dorsi behind, and the great 
serratus and the angularis scapula which only come into 
action when the shoulder is nearly severed. It only re- 
mains, therefore, to separate the skin from the limb and 
divide the pectoral muscles in order to readily draw the 
leg away by traction. Divide the skin around the pastern. 
Have two or three assistants exert traction upon the limb 
while the operator places his hand against the sternum and 
pushes in the opposite direction. Or the operator may in- 
crease his repulsion by using the repeller and pushing upon 
the crutch with his hand while an assistant pushes upon 
the repeller handle. The impact upon the maternal organs 
due to the traction may be reduced to almost any desired 
degree by applying a corresponding amount of repelling 
force to the sternum of the fetus. If the repelling force 
applied to the fetal sternum equals the traction upon the 
limb, the impact of the fetus against the maternal organs 
becomes nil. 

If traction does not bring the limb away promptly, the 
operator should attempt to extend the division of the 
muscles attaching it to the thorax while moderate traction 
is continued. 

Further diminution of the size of the fetus may now be had 
by removal of the other limb in the same manner which is 
especially desirable in the transverse presentation with all 
four limbs in the passages, or the size of the trunk may be 
reduced by evisceration as described under 59. 

This diminution suffices to permit the torso to be 
withdrawn with the head deviated to the side, because the 
total volume is then no greater than with the head 
normally presented. It also renders the fetal body 
very flaccid, and easy of repulsion and simplifies the cor- 
rection of an}' deviations of parts. 



DETRUNCATION 181 



54. AMPUTATION AT HUMERO-RADIAL 
ARTICULATION 

Object. Amputation at this point is rarely desirable, but 
may at times be necessary in the mare in order to remove 
an anterior limb when it is impossible to reach the shoulder 
on account of the position. 

Technic. Attach a cord to the pastern and have an as- 
sistant render the leg tense by exerting moderate traction, 
as in the preceding. Introduce the hand armed with the 
embryotomy knife, carefully concealed in the palm, and 
girdle the skin around the articulation. Passing above the 
head of the olecranon on the posterior side, divide the at- 
tachment of the anconean group of muscles with the knife 
by cutting from behind forward. Then divide transversely, 
as far as possible, the muscles and ligaments passing over 
the articulation. Rotate the limb forcibly on its long axis 
while strong traction is maintained, and rupture the princi- 
pal ligaments until the limb is completely detached and 
comes away. In cases of limited room it may sometimes be 
easier to detach the skin of the limb from the pastern up 
to the articulation, as in the preceding chapter, rather than 
to girdle it. 



55. DETRUNCATION 
Fig. 70 

Object. In the mare a fetus in the anterior presentation 
and dorso-sacral position sometimes has one or both poste- 
rior limbs deviated forward and the feet engaged in or 
against the pelvis. It may then be necessary, or at least 
advisable, to divide the trunk of the fetus in order to bring 
about delivery without serious or fatal injury to the mother. 

Techn'lC. If possible, secure the two hind feet by means 
of cords, prior to other manipulations. Apply cords to the 







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184 DETRUNCATION 



two anterior limbs and the head, have one or two assistants 
draw the anterior part of the fetus as far out as practicable 
and safe, and then girdle the fetal body immediately against 
the maternal vulva by making an incision through the skin 
and skin muscle. If practicable it is best at this point to 
remove one shoulder subcutaneously, and follow by 
evisceration, in order to give greater operative room 
and increased mobility of the fetus. Insinuate the hand 
between the skin and the deeper structures and forcibly 
separate the integument from the fetal body backward until 
the last rib is passed, as shown at the curved line in Fig. 
70. Force the ringer tips through the abdominal wall be- 
hind the last rib and passing along the entire border of 
each posterior rib, separate the abdominal walls from the 
ribs and sternum. After the abdominal muscles have been 
detached, and the fetus has been eviscerated, rotate the 
thorax upon its long axis which will cause a division of the 
vertebral column near the dorsal-lumbar articulation and 
the anterior portion of the fetus to fall away. 

Secure the two posterior feet with cords, unless this has 
already been done, spread the detached skin, which has 
been pushed back from the thorax, carefully over the 
amputation stump of the lumbar vertebrae, repel these by 
means of the hand while an assistant draws upon the cords 
attached to the feet, push the remnant of the fetal trunk 
into the uterus and advance the feet along the genital pass- 
ages, thus converting it into a posterior presentation. 
Ordinarily this would result in a dorso-pubic position. 
This should be converted into the dorso-sacral position, 
when its extraction can be readily brought about. 



DESTRUCTION OF THE PELVIC GIRDLE 135 

56. DESTRUCTION OF THE PELVIC GIRDLE IN THE 
ANTERIOR PRESENTATION 

Fig. 71 

Object. In somewhat rare instances, perhaps most fre- 
quently in the cow, the pelves of the mother and fetus be- 
come interlocked, the antero-external angle of the fetal 
ilium, I', becoming locked with the shaft of the maternal 
ilium, I, at C in such a manner that any safe degree of trac- 
tion fails to dislodge it. 

The interlocking is generally, if not always, caused by 
traction wrongly applied. At the stage of expulsion or ex- 
traction of the fetus, when the interlocking occurs, any 
traction applied should be parallel to the long axes of the 
posterior limbs of the cow : the head of the fetus should be 
directed toward the hind feet of the cow. 

Technic. Remove one anterior limb subcutaneously, 
(53) and eviscerate, (59) through an opening made by the re- 
moval of two or three of the exposed ribs. Introduce the 
chisel through this opening, carry it back with the 
hand, place it against the shaft of the fetal ilium, I', and have 
an assistant drive it through the bone from before to behind. 
Revolve the chisel forcibly on its long axis to completely 
break down the ilium and its periosteum. Then withdraw 
the chisel, place it against the pubic brim either at the 
symphysis pubis or opposite the obturator foramen, and 
drive it through the pubis and ichium at either of these 
points. The coxo-femoral articulation is thus detached 
and isolated so that the entire limb may drop backward be- 
yond its fellow, the remnant of the severed ilium, I', can 
drop downward or move in any direction, the entire pelvis 
thus loses its rigidity and undergoes great diminution in 
size so that it can readily be withdrawn. 



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188 AMPUTATION OF THE LIMBS AT THE TARSUS 



57. AMPUTATION OF THE LIMBS AT THE TARSUS 



Object. In the mare and cow, when the fetus presents 
posteriorly with the hind limbs retained at the hocks, it is 
sometimes impossible or imprudent to correct the deviation. 
This is especially true when the fetus is dead and emphysem- 
atous. In these cases it is sometimes easier for the ob- 
stetrist, and safer for the mother, to amputate the limb at the 
tarsus. 

Technic. Pass a cord around the leg above the tarsus as 
indicated in Fig. 72, and have an assistant hold the leg 
steady by gentle traction. Introduce the chisel, carefully 
guarded in the palm of the hand, and place it against the 
lower part of the tarsus as shown between T, T. The 
chisel should be placed as nearly as possible perpendicular 
to the long axis of the metatarsus. The proper direction 
of the chisel may at times be greatly favored by placing the 
cord upon the metatarsus instead of the tibia, thus forcing 
the tarsus toward the sacrum of the mother and tending to 
throw the metatarsus straight across the pelvic cavity. 
When the fetus is in the dorso-sacral position and it is de- 
sired to amputate the left limb, the chisel should be held 
in the palm of the left hand with its dorsal surface against 
the vaginal walls and the instrument carefully guarded and 
guided during the entire operation. The amputation should 
preferably be through the lower section of the tarsus but 
may be made through the head of the metatarsus. Do not 
drive the chisel entirely through the hock without removal 
as it may become caught and clamped between the divided 
bones, but drive for a few inches along the lateral side, being 
sure that the skin at that point is severed along with the 
bone, then loosen the chisel by rotation and lateral motion 
and drive somewhat deeper into the tarsus until it is com- 
pletely severed. Withdraw the severed metatarsus, re- 




3& 



190 INTRA-PELVIC AMPUTATION OF POSTERIOR LIMBS 

move any dangerous spicules of bone remaining on the 
stump and see that the latter is safely secured by a cord 
passing around the leg above the os calcis. Repeat the 
operation on the other hock in a similar manner using the 
right hand to guide the chisel. Extend the two limbs into 
the passage by traction and effect a posterior delivery. 



58. INTRA-PELVIC AMPUTATION OF THE POSTERIOR 
LIMBS, BREECH PRESENTATION 



Uses. The overcoming of dystocia due to a posterior 
presentation with the hind limbs completely retained in the 
uterus, the so-called breech presentation, in cases where the 
deviation can not be readily corrected. 

Technic. Introduce one hand, armed with the embryotomy 
knife, through the maternal passages until the perineum of 
the fetus is reached, make a free incision through that 
region, involving the anus in the male fetus and the anus 
and vulva in the female, and enlarge the incision sufficiently 
to admit the operator's ringers into the fetal pelvis. Locate 
the great sciatic ligament and with the knife or chisel 
divide it from end to end, thus enlarging the pelvic 
cavity and giving ample operating room. When this has 
been severed and sufficient operating room attained, carry 
the chisel with the hand, place it against the shaft of 
the ilium as shown between I' I' in Fig. 73, as nearly per- 
pendicular to the long axis of the iliac shaft as possible and 
keeping the hand in touch with the chisel blade, have an 
assistant drive it through the bone until it and its periosteum 
are completely severed. Revolve the chisel on its long axis 
and force the cut ends of the bone apart. Disengage the 
chisel and place it against the symphysis pubis or against 
the ischium opposite the obturator foramen and dri'-e it 



192 IXTRA-PELVIC AMPUTATION OF POSTERIOR LIMBS 



through the ischium aud pubis at this point. Revolve the 
chisel upon its long axis and separate the isolated portion of 
the pelvis as completely as practicable from the surrounding 
tissues. Separate the muscles with the fingers from the 
detached pelvic bone for a short distance from the severed 
ends on either side. The most important point of resistance 
is the attachment posteriorly of the skin, vulva and anus to 
the sciatic ligament and the ischium and anteriorly, chiefly on 
the median line, the prepubic tendon to the pubic brim ; 
these are to be cut, if necessary, with the chisel or knife. 
The next most important obstacle to tearing away of the 
limb is the great gluteus muscle which should be sought for, 
identified and torn through with the fingers at a distance of 5 
or 6 cm. from its attachment to the great trochanter. Carry 
a cord in, pass the loop over the ends of the severed section 
and, tightening it, secure the isolated portion of the pelvis 
and have one or more assistants exert traction as indicated in 
Fig. 74. Vigorous traction may be applied by means of the 
cord, the operator in the meantime guarding the most ad- 
vanced end of the detached piece of pelvis with the palm of 
his hand in order to prevent injury to the maternal organs. 
Sometimes this detached piece of the pelvis tears away from 
the femur when traction is applied, and comes away alone. 
In such a case the cord is to be applied over the head and 
trochanter of the femur and traction again applied drawing 
the limb away in a reversed position, the skin being turned 
back or everted as it advances, until the region of the hock 
is reached where the integument does not so readily separate 
and only requires to be cut loose and the member allowed 
to come away. During the removal of the limb the operator 
is to constantly note the progress with his hand and sever 
by tearing or cutting any tendons or muscles which offer 
special obstruction to the operation. Repeat the operation 
upon the opposite limb in the same manner except that but 
one incision need be made through the bone, that is, through 



194 EVISCERATION 



the shaft of the ilium. During the entire work the opera- 
tion is carried out subcutaneously or rather intra-fetally 
and the maternal parts are amply guarded against injury. 
The size of the fetal trunk may be further reduced if de- 
sirable, by evisceration, (60), and followed still further by 
the introduction of the chisel guided by the hand and the 
ribs, on one or both sides, severed one after another until 
the chest can completely collapse. Or the ribs may be yet 
more conveniently severed by introducing the sector in the 
body cavity, pushing it forward until the first rib is reached, 
catching the spherical end over the rib and drawing back- 
ward, severing each rib in turn. If need be, some of these 
may be removed and one of the anterior limbs caught by a 
cord around the scapula and the fore leg extracted intra- 
fetally. The remnant of the fetus is to be extracted by 
means of a cord fastened about the lumbar region of the 
spine. 



59. EVISCERATION 

Evisceration of the fetus is frequently desirable in ob- 
stetric practice and has a variety of uses. It decreases the 
size of the fetal trunk greatly and permits its more ready 
passage through the genital canal, as in the anterior presen- 
tation ; it renders the fetal trunk flaccid through the re- 
moval of the viscera supporting the body walls, and 
permits the body remnant to be bent or moved more read- 
ily for the correction of any mal-presentation like that of 
the lateral deviation of the head ; it permits freedom of in- 
tra-fetal operations directed against other parts, as for de- 
truncation, or for the destruction of the pelvic girdle in 
the anterior presentation ; and when a fetus is emphysema- 
tous, evisceration permits the gases of decomposition to 
pass into the fetal body cavity and thence externally. The 
escape of gases is very greatly favored further by the 
cutting of the ribs. 



EVISCERATION 195 



Technic. Evisceration may be variously performed, but 
is generally demanded in either the anterior or posterior 
presentation and a description of these will suffice. 

In the anterior presentation, unless the fetus is far ad- 
vanced through the vulva, evisceration is best performed by 
the removal of one or more of the anterior ribs. The ribs 
are generally best reached by the removal of the shoulder, 
as already described under subcutaneous amputation of the 
anterior limbs (54). When the ribs have been laid bare in 
the manner described, the operator can thrust the finger tips 
through the intercostal muscles in the first space and en- 
large the opening thus made by tearing through the mus- 
cles upward to the spinal column and downward to the 
sternum ; then grasping the posterior border of the rib near 
its middle, fracture it by means of a sudden and vigorous 
pull. The fractured ends may then be grasped and pulled, 
broken, or twisted off. The chisel may be brought into use, 
if required, in order to divide the rib, the hand of the opera- 
tor constantly guiding and guarding the chisel blade. The 
operation is then to be repeated, if required, upon the second 
and third ribs in the same manner until an opening into the 
chest is secured ample in size for the introduction of the 
operator's hand. 

Pass one hand through the opening and tear the medias- 
tium above and below from the thoracic walls, and then 
grasp either the trachea at its bifurcation or the heart and 
tear them away. The heart, which constitutes the greater 
bulk of the thoracic viscera, is best grasped in the palm of 
the hand with the fingers engaging the aorta and pulmo- 
nary arteries. When the thoracic viscera have been with- 
drawn, thrust the fingers through the diaphragm and loca- 
ting the liver, isolate the diaphragmatic area to which it is 
attached, and engaging both with the fingers remove the 
two together. The liver constitutes, in a normal fetus, the 
chief intra-abdominal mass, occupying more space than all 



196 EVISCERATION 



other organs combined. After the liver has been removed, 
the intestinal tube, with its contents, is withdrawn without 
difficulty, as its attachments are feeble. The kidneys may 
also be removed. 

Evisceration in the posterior presentation is preferably 
performed through the pelvis, generally in connection with 
intra-pelvic amputation of the posterior limbs (59). It may 
be performed without destruction of the pelvic girdle by 
making an incision through the perineal region and by then 
severing the sacro-sciatic ligament as directed under 59. 
When admission has been gained to the abdominal cavity, 
introduce the hand and withdraw the alimentary tube, then 
rupture the diaphragm about the liver and tear away the 
latter organ in the same manner as in the anterior presen- 
tation. The liver is so friable that it cannot well be re- 
moved by grasping the organ itself, but comes away entire 
with the central part of the diaphragm. 

Remove the heart and lungs as above directed. 



